Any parent of multiple children can tell you that keeping track of their family’s medical history can be a challenge!  Every time I am asked for a child’s birthdate, I have to pause and think, let alone their most recent weight and height!  Back when I had one child, I could rattle off every state from the previous six months.  Now?  I know how big each of them was at birth…and that’s about it!

Technology simplifies keeping track of each family member’s personal health records. Just this morning I was filling out a form for a new doctor’s visit and I was able to refer to our electronic records to fill out my little one’s most recent height and weight.  These days it seems that your entire life can be accessed from your mobile device and it only makes sense that your family’s health information should be just as accessible, especially in emergency situations. If you have more than one child, it can be difficult, for even the most diligent of moms, to keep track of each child’s detailed record of immunizations, allergies, etc. How many times have you looked at a bottle of acetaminophen and tried to remember if your child gets one teaspoon or one and a half teaspoons?

There are a few categories of health related apps that I would like to highlight:

1. Medical Records
   If you do a search on TheiPhoneMom.com for the terms “medical” or “health”, you will come up with numerous results.  Most recently, we reviewed Microsoft Health Vault and Family Med Track.  Both of these apps allow you to store a complete medical history for multiple family members including medications, immunizations, health conditions, allergies and more.  They each have unique functions, so be sure to read up on all that they can do.  Medical record apps really allow you to have your full family medical history at your fingertips at all times making doctor’s visits much easier.   My Kid’s Healthfeatures a great display to keep track of milestones in weight, height, head circumference as well as vaccinations, appointment, allergies and illnesses.
2. Illness/Symptom Guides
   Do you ever obsess over your children’s symptoms?  A few days after one of my children’s friends had her appendix removed, one of my children had a stomachache. Who did I turn to?  Dr. Google!  Googling every symptom is not recommended by doctors as you can either miss important things that need treatment, or work yourself up into a panic over a simple virus. One great app for checking symptoms is the Merck Manual: Home Edition. It’s written simply and has been put together by hundreds of medical experts. iTriage is another symptom tracker app that was created by two emergency room physicians in order to help you figure out what you might be dealing with and where you should go to seek help. You can even connect this to your Microsoft Health Vault account.  Finally, for an emergency situation Medlert 911+works as an emergency response app, connecting you quickly with those you have designated as your emergency contacts.
3. CPR and First Aid
   I am a strong believer in a hands-on CPR and first aid course for anyone who lives with or works with children.  In an emergency, it is helpful to be trained so that your response is automatic.  Some babies tend to gag and choke when eating solids and if you know how to quickly flip them over your arm and pat their back, you will be much more confident in facing these challenges!  I have two apps in my “to be reviewed” folder that are waiting on a full write up. First Aid by American Red Crossis a comprehensive guide that takes you step by step through first aid and CPR responses to emergency situations.   Pocket CPR focuses on CPR only and includes a training program that allows you to see if your rhythm is correct.
4. Role Playing Games
   Finally, for any kids who are apprehensive of doctors, role playing games can help prepare them for their next visit. Play Hospital is a cute game that walks kids through each step of a doctor visit.

When we started here at DrGreene.com there was just one doc answering questions online. As the years have gone by the amount of health information (all information) has exploded. But even so, there haven’t been all that many docs answering questions online. Until recently…

According to Ron Gutman, CEO of HeathTap, “There’s a new movement in healthcare – and it’s growing from a surprising place.  Instead of emerging from government or industry, it’s budding from the grassroots –from everyday physicians. The movement is democratizing health information and giving birth to a new landscape: Interactive Health.” You can read the entire article at The HealthCare Blog. I’m privileged to be their Medical Director and excited about the amazing physician network forming there.

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.  Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

This piece was originally published in Zocalo Public Square, an online magazine of ideas. 

Medscape Pediatrics, a leading source of medical information for physicians (if not the leading source of info for physicians), has released the Medscape Top 10 for in 2011 – this year’s 10 most important articles, chosen by being the most read articles of the year. ***Spoiler Alert*** This is tremendous news for WhiteOut, our campaign to upgrade from white rice cereal for babies. What pediatricians are reading:

10. An article on the best way to sedate kids who need a head CT.

9. Recommendations for safe sleep for babies.

8. The Immunization Resource Center – a very hot topic indeed.

7. Is acetaminophen harmful in children?

6. New guidelines on when the tonsils should come out – and when not.

5. New guidelines for managing iron deficiency.

4. New Guidelines on managing urinary tract infections in children.

3. New Children’s Hospital Rankings.

2. Struggling to live on a pediatrician’s salary – rising costs and stagnant reimbursements.

And… drumroll please… The most read article of the year on Medscape Pediatrics:

1. Starting Solid Foods: Are We Doing it Right? – Is the decades old practice of starting infants on white rice cereal the best practice? This is a story about WhiteOut.

Even though white rice cereal was the most recommended first food before the article – by almost 2 to 1 – of more 12,000 physicians who took part in a Medscape pre- and post- survey, 93% of those who responded after reading the article would not recommend white rice cereal.

Thanks to everyone* who has helped spread the WhiteOut word! People working together can change the world. The job’s not done yet, but together we can make this a lasting change for our kids.

^{*Special thanks to Richard Sachs, Karen Herzog, Beverly Richardson, Sylvia Tawse, Matthew Holt, and Christopher Gavigan.}

I’m sure that you are familiar with the old saying “mom is the heart of the home”.  But let’s take that one step further and bring it into our health conscience world with the new saying of “home is the heart of health”.  What do I mean by that?  Well, if you look at the health movement today, you will observe that most tools or techniques are designed to improve health for individuals, as a result, their success is limited and often fail.  Take for example, your last attempt at improving your eating habits (read diet).  If you were the only one in your household trying to improve in this area and one of your family members brought home a fresh, warm pizza, you probably abandoned your commitment and enjoyed the pizza.

When we are looking at improving health, we need to look at ways in which we can use effective tools and techniques in the context of the household, not individually, for the greatest success.  How do you do this?  Simple…Let’s walk through a system that identifies strong and weak areas of health in your household. Once you determine what your weak link is, it will be much easier to find solutions that fit your family for improvement in that area.

In this system, there are five areas of health that you will assign a numerical value for each member of your family (household).  This process is called the Family Health 360 Walk Through because it allows you to look full circle at your family’s health.  Here are the areas:

Nutrition Physical Activity Rest & Recharge  (sleep, stress management, meditation, etc.) Connect & Care  (social, emotional, mental & spiritual health) Protect & Prevent  (preventive measures ie: flossing, mammograms, eliminating environmental toxins and risks, etc.)

Now take out a piece of paper and draw out a grid like the one you see below.  At the top of each column, write the name of a family member (there are five columns in this example, but you may have more or fewer than five people in your family).  In the empty boxes next to the area of health and under each family member’s name, rate them on a scale of 1 – 5 for that area.

1= not good 5= good

Once you have rated all members of your family, you will most likely see a “family trend” of health.  Next, add the numbers in each health area horizontally for a grand total in each area.  Then, divide each grand total by the number of members of your family (averaging).  This gives you your Family Health Score in each area. The area of health with the smallest Family Health Score is your weak link.

With this knowledge, you are now more aware of your family’s strengths and weaknesses. This knowledge allows you to make better decisions in improving health in the context of your household.

What did you learn by using this system?  What surprised you?

What is Your Family’s Health Score?

My son was about six when I got off of sugar and wheat. I saw how great it was for me, so I thought, “What if I could do the same for him?” But how do you tell a six year old: No more sugar? So I used Craig’s suggestion. I told my son, “We’re going to try to not have any sugar and wheat for one week and see if your allergies improve.” He wasn’t thrilled, but I said, “It’s only for one week.” He didn’t argue with that.

My son’s allergies are not bad. He rarely needs an inhaler, but he takes an allergy pill daily. The symptoms usually surface when he gets a cold and it goes into his lungs. Then he needs the inhaler, antibiotics, or maybe a trip to the doctor for an extra-strong inhaler treatment. Once he had to go to the ER for this treatment. That was scary. No parent should have to worry like that. So what if getting him off of sugar meant that wouldn’t happen anymore? I had to try and see.

I had to look at the ingredients in everything my son ate. I was already doing this for me, but there’s so much sugar in the things kids eat. And then finding food that didn’t have wheat or gluten too? Most products have one or the other. It meant I cooked a lot more, which was fine because I like cooking.  We also upped his intake of veggies. Luckily he likes eating carrots and celery as snacks. It requires a lot of planning, but eventually becomes second nature.

After a week, my son got a cold. Probably his body’s way of detoxing. But this was the first cold in six years that went away on its own and didn’t turn into a visit to the doctor’s along with antibiotics or extra inhaler treatments. I was amazed. When I told him what happened, excitedly he said, “Mom, I hate antibiotics!” He was so happy that being off of sugar and wheat meant no antibiotics and no meds, he was ready to be a partner in giving up sugar. I didn’t have to make him. He wanted to live this healthier lifestyle too.

After the first week, I let him have gluten and sugar on weekends. I figured, he’s not allergic to them, he should be able to have them in moderation, because it doesn’t cause any problems for him. I figured a kid needs to be able to enjoy “normal” foods at times and not feel like they’re missing out. Since we’ve changed to this diet, every cold he’s had hasn’t turned into anything serious where antibiotics or extra inhaler treatments were needed. And minimizing his wheat intake has helped his stomach immensely. Whenever he goes overboard, like on vacations, he regrets it because he gets a bad stomachache or needs the inhaler.

As for me, it had been over a year and I was still med-free. At my check-up, my pulmonary doctor was almost in shock when I toId him I didn’t need meds anymore and I was back to my active lifestyle. So after all I went through, you’d think I’d learned my lesson with the fertilizer. You’d think…!

I was honored to take part in the recent Health 2.0 conference. In the video you’ll meet one of the regular members of our community. Interestingly, I had no idea what she looked like until seeing her onscreen even though we’ve chatted many times about her children and their health.

Perspectives from living many places in a few short years – Part 3: A few healthcare issues I have noticed

Living the life of a nomad for the past three years has exposed me to several healthcare issues around the US.  Here are two issues I discovered.

In Jackson, Mississippi, there are a lot of premature babies being born, and a lot of babies born to young teenage moms.  I remember one mom was 13 and her sister was 15 with 2 kids.  Mississippi has high rates of teen pregnancy and obesity.  Obesity goes along with malnutrition, both of which are contributing factors to the number of premature babies being delivered.   Being able to save these babies is a modern day medical miracle, but usually (though not always) it is safer for the baby to be delivered at term.  We need better nutrition, education, prenatal care, and medical access to care if we want prematurity and teenage pregnancy rates to decline.  Easier said than done.  What suggestions do you have?  Please post comments with your thoughts.

In Chicago, over the course of a few months I watched a woman deteriorate: she had asthma and she liked to drink.  In January she was admitted under our care for asthma attacks; her asthma was very poorly controlled.  Our attending doctor told her how severe her asthma was and how necessary good control was.  He spoke with her about her drinking, and we made sure she went home with her asthma medication.  Again in March she was admitted for an asthma attack.  Again, we made sure she had her medicines and that she knew she must stop drinking.  In June, when I was in the ER rotation, she was being seen for chest pain.  I remember noticing how thin, anxious, emotional and sick she looked.  Her chest pain was due to asthma, and how she looked was due to months of not taking care of herself. I can’t forget how she cried while admitting to continuing to drink.  She had literally wasted away; we stopped her asthma attacks, sent her home with her medications and instructions to stop drinking with resources for how.  I felt sad in seeing her waste away; I only imagined what was to come.  This isn’t a story particular to Chicago and it isn’t a pediatric story.  Medical problems and mental health issues, complicated by poor self-care, plague people of all ages everywhere.  Certain areas of the country have limited health care follow up.  People are seen when they are sick but often there is no continual care to ask, “How are things going?”  We need more medical follow up to really help people of all ages with chronic medical and mental health issues.  Are there medical follow up issues in your area?  Please post comments to let us all know.

More than 9 million children lack health insurance and millions more have inadequate coverage. This means one out of every eight children in the U.S. won’t get the correct healthcare. (2) A child’s health impacts every aspect of their life. A healthy child does better in and misses less school, giving them a better chance at success in life. It’s a pretty simple equation. Healthcare = healthy child = More successful adult.

So, what can we each do to help?

• If you know a family that has lost their healthcare thanks to the current state of the economy, educate them on Medicaid and SCHIP programs. These programs cover approximately 34 million poor and near poor children. In many cases, parents don’t know that their children qualify for these programs.
• Donate to children-specific hospitals. There are a number of Children’s Hospitals across the U.S. Each of these hospitals provides free care for a number of children a year.
• Get Involved. Write your state officials and tell them you want a change in healthcare for children.

Our children are a precious resource and should be treated as such. Let’s do our part to keep them all healthy!

(2) HealthPAC online

The pediatric hospital I worked at was built out of the old residence compound for the Mexican Ambassador. This is not an absurd transition as many of the hospitals, schools, and orphanages in Port Au Prince were transformed from some other structure previously used for a completely different purpose or by a different political regime. Some hospitals were staffed by local physicians, some had residents who were a part of the medical education system, some by rotating international volunteers, and few almost entirely by nurses and community healthcare workers. I visited a clinic with electronic medical records that disposed of their used needles by dropping them in a bin outside the door. Haiti’s healthcare system, if any, was disorganized and inconsistent.

The potential of creating infrastructure from scratch is one that can be appreciated by all (especially those of us in the US). The goal should no longer be to leave the country in the state it was before the earthquake; the complete destruction of the infrastructure has forced the solution of rebuilding, as opposed to fixing. And this distinction is important when considering the possibility of creating something better than was in prior existence. Haiti has the unique opportunity of building a system from the ground up. Finally it is Haiti that will benefit from the trial and error of the rest of the world, as it takes from our successes and failures and crafts a system from these lessons. Supported by experts around the world as well as millions of dollars in resources, I can’t wait to see what is sculpted from this struggling, destroyed, blank system.