Pushing back against the war on vaccines

It was bound to happen eventually on my pediatrics rotation: coming across parents who for one reason or another refuse to vaccinate their children.

The most recent anti-vaccination movement stems from a 1998 Lancet article that ostensibly showed a link between the measles, mumps and rubella (MMR) vaccine and a so-called "bowel-brain syndrome" that involves non-specific bowel inflammation and a regressive type of autism. Vaccination opponents seized upon this article as legitimization of their views while the medical community collectively gasped.

Much has been written about the methodological and ethical problems with the study; a lot of time and energy was invested into reproducing or disproving the results of this study. Ultimately, though, it was an investigative journalist who showed that the author of MMR-autism study had allegedly cooked the data for financial gain (How the case against the MMR vaccine was fixed, British Medical Journal, 5 JAN 2011). This led to a formal investigation, public censure of the primary author, and the paper's retraction more than a decade after its publication.

But not before the damage was done. The authors of this paper used a respected and authoritative medical journal as a platform to spread what appear to be lies, the result of which was millions of parents questioning whether they should give their children the MMR vaccine - or any vaccine - for fear that it will cause autism. Many parents who had the misfortune of learning that their child has autism, desperately searching for reason, have stumbled upon the falsehoods spread by this article that seemingly explain the unexplainable.

Vaccinating children: Keeping the dialogue open

This is a dilemma faced by pediatricians worldwide, dealing with parents who are skeptical of vaccines or who flat-out refuse to vaccinate their children.

One such parent stood out over the course of my pediatrics rotation. She is the mother of an autistic child who hadn't received any vaccinations since 18 months and was coming in for a well-child visit. My preceptor warned me that this child's immunizations were not up to date and that the mother would likely continue to refuse all vaccinations. "What's your approach to such a parent?" I asked because some pediatricians (including one provider who I worked with previously) just have the parent sign a form without any discussion. "I always keep the patient in my practice, and I try to keep the dialogue open," she replied.

So, when it came time to talk about immunizations, I jumped right in:

"It seems that he's not up to date on his immunizations. Which shots do you want him to get today?"

Mom replied: "I don't want him to get any shots."

Feigned surprise: "Why not?"

"I just don't. He doesn't need them."

"Why do you think he doesn't need immunizations?"

"He just doesn't. He's not going to get sick."

My preceptor interjected: "Do you think there's a link between vaccinations and your son's autism? The only scientific publication that suggested a link was--"

"No, I don't believe that."

I sat back and thought for a few moments, perhaps slightly theatrically. "Tell me, what's your understanding of the diseases that these vaccinations protect against?" This question seemed to catch Mom off guard. The door was cracked slightly open, so I took the opportunity to educate Mom about hepatitis A and measles and mumps and rubella and chicken pox....

Oops, tactical error. Mom jumped on the chicken pox: "See, why does my son have to get a shot for chicken pox? I had it when I was a kid, and I did just fine!"

My preceptor rescued me: "Before we started vaccinating against chicken pox, a few hundred kids died from it every year. Percentage-wise, that might not sound like a lot, but if it's your kid who doesn't come home from the hospital because of chicken pox, then those chances are 100% for you. Did you have any complications from your chicken pox?"

"Yes, I was hospitalized for two days."

Then my preceptor closed the deal: "Well, it would be a horrible shame if your boy had to go through something like that if he didn't need to."

In the end, Mom agreed to vaccinate her boy against hepatitis A, influenza, and chicken pox, all that same day. She also agreed to vaccinate him against measles, mumps, and rubella, only if we could give those as separate shots.

Done!

I felt a real sense of accomplishment. Partially because of me, this little boy would now be protected against several serious diseases.

My opinion: Why every child should be vaccinated

Vaccines in general arguably represent the single most important development in medicine, ever. Some people may counter that antibiotics are a more significant advancement, and I'll give them that it would be a good debate.

But think for a moment: What would the world be like today if no vaccine had ever been developed? Just for starters, the world would still be ravaged by smallpox, a disease that few people can truly appreciate how devastating it really was. To put this in perspective, the Wikipedia page refers to smallpox in the past tense, citing its eradication in 1979! Then there's polio, which is so very close to also being referred to in the past tense thanks to a coordinated worldwide campaign to eradicate polio. Warehouses full of people living inside iron lungs are a nightmare of the past; we will never again have a President of the United States confined to a wheelchair because of polio.

Measles (one of the M's in MMR) is a great example of a horrific disease that practically disappeared because of population-wide vaccination but has recently made a resurgence, partly owing to the people who were never vaccinated against it. Measles is an incredibly infectious disease, which means that it's very easy to spread from one person to another. That in turn means that eradicating it will be that much more difficult, especially if there are significant pockets of the population who are susceptible to it. Recently, PBS reported on a mini-outbreak of 13 measles cases after the 2012 Super Bowl; all 13 cases had opted out of the MMR vaccine. In developed countries, one person will die of measles for every 1000 people who get the disease; mortality jumps to 5-10% for measles infections in developing countries (PLoS Med. 2007 January; 4(1): e24). Those are odds I wouldn't want to play around with.

The logic is simple: If you're vaccinated against Disease X, then you will not get Disease X. Given that the consequences of getting many of these preventable diseases include permanent disability, or worse, death, it's hard for me to understand why loving parents would would choose to not vaccinate their child.

A special mentor

The second half of my pediatrics clerkship was much better than the first half. This was partially thanks to working in a practice that focuses on special needs children, an interesting twist to what otherwise would have been three weeks of garden variety ear infections, upper respiratory infections, and stomach aches. But I mainly attribute the quality of my outpatient pediatrics experience to my preceptor. She's a role model for the kind of physician I hope to become, even if I won't be going into pediatrics.

She makes a real difference in her patients' lives; they travel surprising distances just to see her. She is a passionate advocate for her patients' physical and mental health in the context of an often hostile health care system. She is an excellent clinician, able to identify the rarest diseases with simple observations accumulated over her decades-long career. And in her spare time, she has traveled throughout the world participating in medical aid missions. She loves what she does and gains true satisfaction from her work.

I wish I could have spent more time with her.

Playing with zebras

There's a saying in medicine: "If you hear hoofbeats behind you, don't turn around and expect to see a zebra." Thus, the term "zebra" in the context of medicine refers to a very rare and unlikely diagnosis.

It just so happens that I am spending the last couple weeks of my pediatrics rotation working at a private practice that specializes in zebras. My preceptor is a pediatrician who provides health maintenance for children with "special needs." In the short time that I have been working at this private practice, I have seen a wide range of diagnoses; no child has been "normal":

• Non-accidental trauma, child abuse, and in utero exposure to alcohol and drugs. These are children with nauseating histories who otherwise would have been lost in this world if they had not been taken in by incredible adoptive parents who love these kids as their own.
• Attention deficit hyperactivity disorder, learning disorders, and developmental delay
• Autism spectrum disorder. These patients take the prize for most exasperated parents.
• Down syndrome. At various ages and levels of severity.
• Fragile X syndrome. I was struck by the variability of presentation. Aggressive behavior was the biggest concern.
• Williams syndrome. Truly a cocktail party personality.
• Prader-Willi syndrome
• Cri du chat syndrome. The child I saw was too old to have the characteristic cry.
• VACTERL syndrome

I can't overstate how helpful, in terms of my medical education, it has been to see in the flesh these patients with rare genetic disorders: to take in the gestalt of their presentation, to interact and play with them, to listen to their parents' experiences raising these children with special needs.

More personally, I am amazed, inspired, and humbled by the depth of love lavished on these children. Regular parenting is a full-time job, but caring for and raising special-needs children demands an enormous amount of fortitude that I cannot fully comprehend.

Sick

It was bound to happen on my pediatrics rotation: I'm sick. What else would I expect from exposure to coughing and sneezing and drooling and runny noses for 12 hours per day over the last 3 weeks? Kids are germ-machines.

I wore a mask when seeing almost all of my patients, always with the sick ones, and I washed my hands like someone with obsessive-compulsive disorder. This past week while on inpatient service, I also wore a gown and latex gloves while seeing all of my patients - required precautions. Apparently, all of that wasn't enough.

Abdominal pain in a child

Of all kids coming to the emergency department complaining of abdominal pain, plain old constipation is to blame 70% of the time. Just such a kid came into the ED, but it turned out to be much more interesting than constipation.

Talking to Mom, I found out that the girl had been having stomach pains intermittently for over a year, that she could be fine one minute but doubled up in pain the next. These episodes came in clusters, were not associated with school, and were separated by months with the last episode happening several weeks ago. She was indeed previously worked up extensively for her abdominal pain ruling out things like appendicitis, pancreatitis, and celiac disease. In fact, an abdominal x-ray a few weeks ago even ruled out constipation.


The little girl last had a bowel movement earlier in the day, and Mom noted it to be soft without excessive straining required to defecate. She also had two bowel movements the previous day. None of this was pointing toward constipation as the cause of this girl's abdominal pain.

My patient was difficult to talk to. She would hardly look at me. Even when I asked her simple questions like "What's your favorite color?" she would look over to Mom, who professed that her daughter was normally very talkative. Mom was also difficult to talk to: she couldn't get words out of her mouth fast enough, she went off on tangents before eventually answering my questions, and she spent a lot of time unloading all her worries about what might be causing her daughter's abdominal pain.

Within a few minutes of entering the room, and without even touching my patient on exam, I was already pretty confident about my diagnosis. This could be delicate and require some tact.

"Are there any significant psychiatric problems in the family?"

Jackpot. Mom described symptoms in herself highly suggestive of no less than three psychiatric diagnoses, all of them undiagnosed and untreated. She also said that the kid's father is on medications for two psychiatric disorders. Further delving into the social history revealed significant turmoil at home, including an absent father and other significant stressors.

After a thorough exam, I explained to Mom that I ruled out the scary stuff that could be causing her kid's tummy pain. I said that the clinical picture doesn't really fit a physical cause and that I thought it was more likely that her daughter's stress or anxiety might be behind her symptoms.

Brace for impact....

But to my surprise, Mom accepted what I had to say: "You know, that makes so much sense. No one has ever suggested that before!" Encouraged, I then explained to her that it is very common for children to convert emotional or psychological stress into physical symptoms and that this is called conversion disorder.

In hindsight, this child in fact didn't have conversion disorder because the diagnostic criteria for conversion disorder require another non-pain neurologic symptom, which this girl did not have. She probably met diagnostic criteria for chronic pain disorder with psychological factors, the treatment of which is psychotherapy and antidepressants.

I explained to Mom that it is really important that her daughter receive prompt treatment for this problem to decrease the chances of her developing other psychiatric problems such as an anxiety disorder. For what it's worth, she said she would follow up with her daughter's primary care physician for a referral to a child psychiatrist. I really hope that actually happens.

Pediatric emergency medicine

For the past two weeks, I've been doing shift work in the Children's emergency department at St. Joe's. I only had to do seven 12-hour shifts over these two weeks, and the rest of the time I had off. While I definitely very much appreciate all the free time it has given me, I have also learned that I like more regularity in my schedule. What's worse is that these shifts are 11a-11p, which has shifted my internal clock back several hours. Returning to a normal routine will be a bit painful.

Most of the patients presented with fever, ear aches, runny nose, cough, vomiting, diarrhea, or a combination of the above. It is flu season, after all. This got to be routine, boring. I also saw a few kids with minor broken bones. There were a few other truly interesting cases, which I'll write about later.

But all in all, I have come to the conclusion that I definitively do not like general pediatrics. Good to know. How does this affect my level of interest in pediatric neurology, a course of training that requires two years of general pediatrics? I still have to figure that out.

Endless ear exams

My least favorite part of the physical exam is looking in ears. It's especially difficult in kids because their ear canals are small and crooked, and of course kids tend to squirm and scream when you try to stick something in their ear. Go figure. But a good ear exam is absolutely essential in pediatrics. That's why I made a point to hammer away at the ear exam until I got the hang of it.


Tough going, at first. Too often I would look in a kid's ears and just see a ball of wax, or the sides of the ear canals but no tympanic membrane. When ear pain wasn't a chief complaint and I wasn't concerned about an ear infection, I just nodded my head reassuringly and continued with my exam. This falls under the category of "Fake it until you make it" - first to avoid alarming parents that they are entrusting the care of their child to such an amateur, and second to protect my own ego. But I would return to my attending, tail between my legs, and sheepishly report "Tympanic membrane not visualized" in the physical exam section of my oral presentation.

The attendings are for the most part understanding that a third year medical student isn't going to do a first-rate ear exam. In fact, they seem to expect it. One attending said, "I don't even expect pediatric interns to give a good ear exam. You have to look at thousands of ears to get good at it." Fair enough. Being that we're in the middle of flu season, I've gotten a good jump-start on those thousands.

I think I'm already getting better. I'm probably visualizing about two-thirds of all the ears I look in, at this point, up from around 0-5%. If there's wax, I remove it and try again. If the kid is squirming, I coach the parent on how to hold the kid down. If the kid is screaming, I ignore it. I'm such a meanie.

But being a heartless sadist has paid off. Today a kid came in tugging at her right ear. I looked in the left ear first, then the right, and thought I saw infection in both. The left ear actually looked much worse with erythema in the canal, no light reflex, and yellowish fluid behind the tympanic membrane obscuring the bony landmarks. I described these details to my attending, aware that they were at odds with the patient's history. After doing her own exam, she said five words that every medical student loves to hear from their attending: "I agree with your findings."

Suturing on children

I feel pretty comfortable at this point suturing a superficial laceration. I've even sutured some lacerations in sensitive areas such as the face and hands. But, man, it's a completely different beast suturing on a screaming squirming child! I didn't try this, thankfully, but I saw several of them during my first week on pediatrics. With one kid, even a hit of Versed wasn't enough to calm him down!

One attending's advice: Immobilization. If you keep them completely immobile, they'll eventually stop trying to move; but if you let them move just a little bit, they'll squirm throughout the entire procedure. Just holding down their arms isn't enough. We used blankets to wrap these kids into burritos to immobilize their arms, legs, and torso all at once.

Another attending's advice: Patience. Make any sensitive movements while the kid is actually crying since they tend to be more still during exhalation. One attending spent what felt like 5 minutes trying to take out a single suture, his hand braced against the child's face steadying the scissors to be ready to snip the suture during the briefest window of calm.

To do a good job suturing on children takes a level of patience and steely nerves that I certainly admire.

Pediatrics orientation

I'm very impressed with the organization of the pediatrics clerkship, so far. The logistics of this clerkship are especially difficult because students do a mix of inpatient and outpatient work, with some maternity wards thrown in. To make matters more complicated, students spend varying amounts of time on each part of the rotation, so everyone's schedule is different. I have two weeks of Urgent Care, a week on inpatient, and three weeks outpatient with a pediatrician in private practice.

Waiting for all the students at orientation this morning were binders with all sorts of useful information: each student's schedule, required assignments, forms to fill out throughout the rotation, grading policies, some selected journal articles and other required reading, etc... These binders looked professional, with color-coded tabs and everything. This may seem inconsequential, but presenting all of this information clearly and organizing it well makes a huge difference in terms of reducing stress and confusion.

Aside from going through the binder section by section, we also had three teaching sessions: infant and child development, pediatric fluids/electrolytes, and pediatric nutrition. All three of these sessions were interesting, engaging, and very relevant for this rotation.

I left the pediatrics orientation feeling like I know what is expected of me in these next 6 weeks and well prepared to meet those expectations.

Starting my pediatrics rotation early

I ostensibly start my pediatrics rotation on Monday, but in reality I began this weekend while visiting my brand-new-to-this-world nephew, all of a week old. He's quite adorable.


As I fended off my family members for the privilege of holding him, I couldn't help but give him a quick once-over. Symmetric eye movements, responds to auditory stimuli, soft non-bulging anterior and posterior fontanelles, good muscle strength and tone, no skin markings, etc.... I cursed myself for leaving my stethoscope at home (joking, mostly).

It felt good to have a baby in my arms, especially one that happens to be my nephew. I'm actually looking forward to my pediatrics clerkship. Considering how much I enjoyed my pediatric neurology rotation, it'll be interesting to see what I think about general pediatrics and whether this experience makes me want to incorporate pediatrics into my future career.