Category Archives: Other

What is a Medical Home?

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A medical home is a way of providing health care based on a trusting partnership between patients, their families, and a primary care team.  Medical homes offer increased access to health care (American Academy of Pediatrics, n.d., Medical Home). In pediatric care, it is especially important that care is not only patient-centered, but also family-centered, because pediatric patients are very reliant on their families. The primary care team, led by a physician or nurse practitioner (also called the primary care provider), oversees the patients’ continuous care over time and across multiple community settings.  Having a medical home facilitates comprehensive care across the numerous components of today’s complicated health care system.  Medical homes promote safe care that is based on research evidence.  Technological resources are used to enhance communication across care settings, allowing for more coordinated care. The care that medical homes provide is compassionate and culturally centered (American Academy of Pediatrics, n.d., Family-Centered Medical Home Overview).

Plateau Pediatrics strives to be an excellent medical home for your child.  We provide easy access to primary health care. We are conveniently located at 3234 Miller Avenue in Crossville. This places us at the heart of Cumberland County just a few minutes from I-40, US-127, and US-70. We offer same day appointments for sick patients and have a nurse phone line available for questions or concerns that do not require office visits. An on-call physician is available after hours by calling the Cumberland Medical Center main phone line and asking for the on-call pediatrician.  We are also available by email at office@plateaupediatrics.com.

We schedule our patients with their primary care providers whenever possible, and this consistency helps build trusting partnerships between patients, their families, and their primary care providers. We recognize that children are cared for in the context of their families, so we attempt to consider family circumstances and needs when planning their care.  As primary care providers, our physicians and nurse practitioners oversee their patients’ care over time, from birth until early adulthood. They also oversee their patients’ care across multiple settings, providing referrals to specialists, recommending counseling or behavioral services, arranging for developmental evaluations, arranging for inpatient treatment at Cumberland Medical Center, and arranging other services as they are needed.

Our primary care providers maintain communication with the other health care professionals who provide care for our patients to allow for comprehensive care that is well coordinated.  Communicating with other health providers also allows for avoidance of needlessly duplicating diagnostic tests. We are committed to providing care that is safe and effective. In order to do this, we practice evidence-based medicine.  This means that the treatment we provide and the care we recommend is based on medical research findings and also takes our patients’ individual values and preferences into account.  We utilize electronic medical records and e-prescribing to enhance clear communication between our practice and other facilities involved in our patients’ care.  Our patients and their families are precious to us, so we seek to treat each person we encounter in our office, on our phones, and through email with the utmost level of compassion.  We appreciate the cultural diversity of our population of patients and families. We strive to be sensitive to cultural differences and to provide treatment and education to our patients and their families in culturally appropriate ways. We seek to overcome language barriers, where they exist, by using a telephone based translation service and by producing many of our educational materials and patient forms and information in both English and Spanish.

References

American Academy of Pediatrics. (n.d.). What is a medical home? Family-Centered Medical Home

            Overview. Retrieved September 19, 2011 from http://www.medicalhomeinfo.org/about/medical_

home/

American Academy of Pediatrics (n.d.). What is a family-centered medical home? Medical Home.

Retrieved September 19, 2011 from http://aap.org/healthtopics/medicalhome.cfm

What do I need to know about special education services for my child?

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Some sections adapted from a May 2010 commentary by Neel Soares, MD

What is a “Section 504 plan?”

Section 504 is a civil rights law that prohibits discrimination against individuals with disabilities. Section 504 ensures that the child with a disability has equal access to an education. The child may receive accommodations and modifications depending on his/her needs, such as:

  • Tailoring homework assignments
  • Extra time for testing
  • Preferential seating
  • Supplementing verbal instructions with visual instructions
  • Organizational assistance
  • Using behavioral management techniques
  • Modifying test delivery

What is an IEP?

An Individualized Education Plan (IEP)is an individualized plan for a public school child who receives special education and related services. It’s developed as a team effort between the teacher, principal, special education teacher, school psychologist, and the family. It is implemented when the parents sign it. Progress toward specific goals are measured and reported to parents. The IEP is reviewed every year, and is re-evaluated every three years (or sooner if needed.)

What’s the difference between a 504 plan and an IEP, and how do I know which one my child should get?

The 504 plan is considered a modification of regular education, while the IEP is part of receiving special education services. A 504 can be implemented faster and more simply, while an IEP is more comprehensive. An IEP permits broader, more comprehensive, and more expensive services not available in a 504. It is also monitored more formally and requires more parental participation. Some children can be best served by a 504 plan and others are best served by an IEP: it depends on the child and his disability.

The school said my child needs a diagnosis in order to continue getting services. Can you give me one now?

The Individuals with Disabilities Education Act (IDEA) does not require a child to be “diagnosed” before receiving special education. Disability classification (1 of 13 classes including speech-language, specific learning disability, autism, and emotional behavior disability) and medical diagnoses are not the same. The IEP team determines whether the child has an eligible disability, and a medical diagnosis is not necessary to obtain or continue getting IEP-driven services. The exception is “developmental delay,” which ages out when the child turns 9. At this time, a more specific diagnosis must be given for the child to continue to receive services.

My child has ADHD, and the teacher told me if he doesn’t get on medication, he can’t stay in class. Is the school allowed to do that?

No. The IDEA 2004 revision prohibits personnel from requiring a child to be medicated to attend school, be evaluated, or get services. The school is obligated to consider a behavior plan.

My child is going to be held back this year. What should I do?

The IEP team can make the determination for grade retention (“holding back a year.”) However, parents can challenge the retention decision, especially if they feel retention was the result of the student not receiving the services specified in the IEP.

When should I take my child to the emergency room?

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Suzanne Berman, M.D

It’s 2 am, and 2 year old Cameron just woke up screaming and pulling at her ears. You pick her up and she’s really hot – the thermometer reads 103. Sounds like that nasty ear infection is back again. The doctor’s office won’t be open for several hours yet, but try explaining that to Cameron! You get dressed and bundle her up, preparing to take her to the emergency room of the local hospital.Hang on a minute there. You’re exhausted, and Cameron’s sick, but….is this really an emergency?

When should I go to the emergency room?

Problems which are life-threatening in a matter of minutes are best handled in a hospital emergency department. For all other problems, it’s really better to call us first, whether our office is open or closed.Problems that the ER is best equipped to handle include:

  • Severe cuts or lacerations
  • A head or neck injury with loss of consciousness or vomiting
  • An altered mental state: either a decrease in the level of consciousness or excessive sleepiness or having uncontrollable agitated behavior
  • Severe burns of all types, including chemical and electrical burns, especially on the face
  • Poisoning, caused by ingesting dangerous chemicals or medications
  • Convulsions lasting more than 15 minutes or any unexpected convulsions
  • A serious animal bite which has broken the skin
  • Difficulty in breathing, uncontrollable choking, or turning blue around the lips
  • Stopping breathing or the pulse stopping
  • Signs of shock, including pale, cold clammy skin and a weak and rapid pulse
  • Severe headache accompanied with vomiting or stiff neck.
For these kinds of problems, go straight to the ER. Call 911 if you need help getting your child there. After your child has been stabilized, the ER staff can call us and let us know what happened.
What about other kinds of illness and injury?

For other problems, please at least call us before going to the emergency room, walk-in clinic, or Prompt Care. If we can discuss the problem with you over the phone first, we can help you determine if it needs to be seen immediately or not. If our office is closed, we’ll help you decide whether it can wait until office hours the next morning.We understand that when your child becomes ill unexpectedly, sometimes it seems like a crisis. It would be great to be able to walk to an ER 24 hours a day and see a doctor right away to reassure you that everything’s ok. But your own pediatrician’s office, who knows your child and has access to your child’s medical record, is just a phone call away. It’s so important to us that your child’s record be complete that we’ve made our ER policy part of our new patient brochure.

Why not just take my child to the emergency room? I hate to bother the doctor with a phone call if it’s late at night.

Here are some reasons why we want to keep your child out of the ER unless he or she really needs to go.

  • The ER can be a scary place for kids. Victims of gunshot wounds, mentally ill patients, drug overdoses, etc. also go to the ER. If those patients are getting cared for in the next room, the sounds and smells can frighten your child.
  • Unless your child is very sick, it can be very slow. Heart attacks and strokes have to take priority over fevers and earaches. Usually, young children end up waiting around. This is rough for any toddler, especially a fussy one.
  • The cost is much higher to visit the ER than a doctor’s office. Because the ER has to have so much staff and specialized equipment ready to go 24 hours a day, the ER has to charge 3-4 times what an office visit costs. Insurance companies don’t like this very much. In fact, your insurance company may charge you as much as $100 if they think your ER visit wasn’t appropriate. Even if you don’t have an ER copay, you still pay indirectly with more tax dollars and higher insurance premiums.
  • The ER doesn’t have your child’s medical history on file. Without access to your medical record, the ER staff may need you to recite your child’s entire previous medical history in order to figure out what’s going on. They may have to repeat blood tests and studies that would be unnecessary if a doctor familiar with your child was there.
  • It may not save you time in the long run. Even if you do go to the ER at 2 am and get a prescription for an ear infection, will the pharmacy be open to fill it? Your time might be better spent at home getting the fever down and making your child comfortable in her own bed until our office opens in the morning.

Continuity of care is important to your pediatrician. It’s frustrating for us to have patients come in the office who are on “two syrup medicines that the ER started.” In order for your child’s record to be complete, we’ll want to know the name and doses of the medications, vital signs, the results of your child’s blood work, etc. Parents may not always remember all those details, but they are important to us. If you can give us adequate notice that your child went to the ER, we can get those ER records and update your child’s chart in our office.Also, don’t worry about “bothering” the doctor with a phone call about an urgent problem. You’re not a bother — you’re child is our patient! Besides, if it’s really an emergency, your child’s doctor does need to know about it.

What is the best way to take my child’s temperature?

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Suzanne Berman, M.D.

Modern digital thermometers are faster than mercury thermometers, don’t have to be shaken down, and are much safer if bit, dropped, or stepped on.

The most accurate temperature measurement in infants and young children is a rectal reading. In school-aged children, an oral measurement is ok to use.

Axillary (armpit) temperatures are ok to use to screen your child’s temperature, but remember they are inaccurate 33% of the time. If an axillary temperature suggests your child has a fever, get a more accurate reading by using an oral or rectal temperature.

Some of the new ear thermometers work well if used correctly, but this takes a lot of practice. We don’t recommend using the forehead strip and forehead “wand” thermometers. They are not really accurate at all.

Regardless of which method you use, please don’t add or subtract degrees to the measurement. Recent evidence demonstrates that doing so, even though it is common practice, confuses the picture. Report to us the actual thermometer reading.

How to take a rectal temperature

Hold the baby on his or her stomach across your lap. Let his or her legs hang down freely. Gently insert the thermometer about 1/2″ into the baby’s rectum. Hold the thermometer between two fingers as you lay the palm of your hand across the baby’s buttocks. Don’t leave the baby alone with the thermometer inserted. Leave the thermometer in for 3 minutes. Be sure to clean the thermometer well with soap and warm water after use.

How to take an oral temperature

Have your child sit or lay down as long as thermometer is in his mouth. Gently insert the thermometer under your child’s tongue as far as it will comfortably go. Hold it in place (or have your child hold it) until the reading is finished. Don’t let your child talk or breathe through his mouth. Be sure the thermometer stays under the tongue by watching the angle of the thermometer. A correctly-placed thermometer should point up. A thermometer that has slipped out of place will be level or point down.

How to take an ear (otic) temperature

Follow instructions that come with the thermometer. Remember that, to get an accurate reading, there must be a good seal around the tip of the thermometer, and the tip must be aimed straight toward the eardrum.

How to take an axillary (armpit) temperature

Have your child sit or lie down. Place the tip of the thermometer into the middle of the armpit, against the child’s bare skin. (Don’t do it through your child’s t-shirt or nightgown.) Hold the thermometer in place with one hand. Keep your child’s arm pressed firmly against his side with your other hand until the reading is taken.

What is EMLA (ouchless shot cream)?

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Suzanne Berman, M.D.
What is EMLA?

EMLA is a cream that is used to numb the skin prior to a procedure, such as starting an IV or giving a vaccine. It is effective in older infants, children, and adults.

How does EMLA work?

EMLA contains lidocaine and prilocaine, medications that have been used for many years as anesthetics in medical and dental offices. EMLA contains these medications in a cream form. An area of skin is cleaned and then cream is applied directly to the skin. A dressing to hold the cream in place covers the spot. (Putting the cream and dressing on is not painful: it’s like putting a Band-Aid on.) After 1-2 hours, the cream numbs the skin tissue underneath. The dressing is removed and the cream is wiped off. Your child can then have his or her procedure with a lot less pain.

There is now a faster-acting preparion of EMLA cream that works in about 15-30 minutes.

How effective is EMLA?

Several studies have shown that EMLA greatly reduces the pain children feel with injections. Most children will feel a pressure sensation, as if their skin was being pressed with a thumb, but won’t feel the sharp stab or prick of the needle. Some children feel absolutely nothing. (Some children will still cry anyway, though, if they see the needle coming!)

Can any child get EMLA?

EMLA is safe and effective in most children. However, we don’t recommend EMLA for:

  • Infants under the age of one month. (They have very thin skin and could absorb too much of the medicine into their bloodstream.)
  • Children with severe liver or kidney disease
  • Children with G6PD deficiency
  • Children with very severe skin disorders
  • Children who are allergic to lidocaine or prilocaine
Are there any side effects to EMLA?

Not many, and they are pretty rare. Occasionally children can have a little redness, swelling, or itching on the skin where the cream was placed. This goes away once the cream is taken off. EMLA is toxic if eaten or if too much is applied accidentally, so of course we treat it with the same respect we give all medications.

How can I get EMLA for my child’s next shots?

EMLA costs about $15 a dose. If your child is over 1 year old, you can get it at your pharmacy with your benefit card and put it on at home before you come to the office. Our nurse can give you instructions on how to do this. Or if you prefer, we can apply the cream in our office and bill your insurance. (Note: Some insurers will not pay for EMLA and EMLA administration. You’ll want to call your insurance company first.)

What is a pediatric nurse practitioner?

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What is a pediatric nurse practitioner?

Pediatric nurse practitioners (PNPs) are health care providers who are dedicated to improving children’s health. Since 1965, PNPs have provided comprehensive care to children and families by focusing on health maintenance and education, illness prevention and minor and chronic illness management. PNPs are pediatric (registered) nurses with advanced education (usually a master’s degree) in pediatric nursing. They meet state licensing, competency standards and continuing education requirements. PNPs are certified by a national certifying agency, guaranteeing expertise and competency maintenance. PNPs serve children and families in an extensive range of practice settings, and work with pediatricians and other health care providers in order to enhance the health care of children.

What do PNPs do?

PNPs serve as pediatric health care providers for well and ill children of all ages. PNPs offer a variety of services including:

  • Provide health maintenance care for children, including well child examinations
  • Perform routine developmental screenings
  • Diagnose and treat common childhood illnesses
  • Provide anticipatory guidance regarding common child health concerns
  • Provide childhood immunizations
  • Perform school physicals
What does this mean at Plateau Pediatrics?

Our nurse practitioners, Kristel Hassler and Emily Johnson, are available for well and sick visits. If for any reason their patients are hospitalized, Dr. Robert, Dr. Suzanne, and Dr. Chrissy manage their care in the hospital.

My child sees another physician. Why won’t you give me a second opinion by e-mail?

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Suzanne Berman, M.D.

We frequently get e-mails regarding health issues of children we’ve never seen. We definitely want you to get the best advice you can for your child, but we don’t feel qualified to provide it for children outside our practice. Here are some reasons why:

  • We have no old records available to review. Looking at a child’s old records — to see a previous pattern of illnesses, medication history, growth charts, developmental history — is indispensable in pediatrics. Without this background information, it’s impossible to give good advice. While parental reports of the problem can be useful, they are not a substitute for a physician’s medical record which provides complete documentation.
  • We haven’t examined the child personally. Without personally seeing the child and assessing him, our advice would be primarily an educated guess only.
  • We want to avoid the “too many cooks” phenomenon. Some doctors approach the same problem differently. There may be more than one correct answer to a problem. However, getting snatches from advice from different doctors, without one doctor comprehensively overseeing the patient’s care, is like the old proverb, “Too many cooks spoil the soup.” Parents are often left frustrated, not knowing which source of information to trust.
  • Legal reasons. Physicians who dispense advice or prescriptions to patients they’ve never met, especially out-of-state patients, have been prosecuted for practicing medicine without a state license in the state where the patient resides. Also, we cannot respond to people who have not signed an e-mail consent form in our office.

But I’m not sure I trust my child’s regular doctor, and/or I’d like to get a second opinion.

Then by all means, get a second opinion. But first, in your next visit to your regular doctor, explain your concerns to him or her. Try to describe exactly what concerns you: Are you afraid your child’s symptom could be the sign of something fatal? Do you think the symptoms are more severe or lasting longer than is typical? Do you need reassurance that your child’s symptoms aren’t that rare or unusual?

Most good doctors don’t feel threatened by a parent’s desire for a second opinion as long as the second opinion will be coming from someone who’s more, or at least equally, knowledgeable. For example, if you need work on your car done, go to a reputable auto mechanic — not a general handyman who tinkers with cars. Get your second opinion from a pediatric specialist who will speak with you and examine your child — not from a non-physician, a parent with “something similar” you met on the Internet, or a physician who doesn’t have much experience with the problem in question. And be sure to let both doctors know that you’ve seen the other — the doctors may want to discuss your child as well, and share information.

Can you recommend a second-opinion doctor for my child in my area?

There are lots of great pediatricians and pediatric specialists out there. In general, we have found that board-certified pediatricians who are members of the American Academy of Pediatrics have the best, most up-to-date information. Some non-pediatrician physicians may not have the training or experience to deal with the unusual or complex problems of children. Most family practitioners spend about 4 months of formal training treating children. Most general practitioners and internists have had no formal training with children, outside of what they learned as medical students. (By comparison, pediatricians spend their entire 36 months of residency focusing on children, with over a year spent just on very sick children: hospitalized children, ICU care, neonatal intensive care, etc.)

Pediatric subspecialists should be board-certified in pediatrics and in the pediatric subspecialty in question. We have found that adult subspecialists (e.g. cardiologists, gastroenterologists, etc. whose training was in internal medicine, not pediatrics) are generally less experienced in the special problems and treatment of children. Typically, their formal training primarily focuses on adults and is limited to only 1-2 months of working with children.

If you live in a medium-sized or large city, there may be a medical school or teaching hospital in your area. Pediatricians with teaching appointments at medical schools and residencies are among our finest clinicians. Because these doctors teach other doctors, they are held to very high standards. Other doctors tend to refer particularly severe or problematic cases to them, so they have a wide experience with unusual problems. These physicians are usually the ones participating in ongoing medical research and have the newest and best information.

Is this drug approved for use in children?

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Robert Berman, M.D.

Doctors like to do things for good reasons. If asked whether a drug is safe or helpful, we like to be able to say not just “I took it, and I’m still alive,” but rather, “10,000 patients tried this drug, and they got better faster than 10,000 who didn’t take the drug, and they suffered no ill effects.” But it hasn’t always been easy to get that kind of information.Before there was a Food and Drug Adminstration (FDA), people could say whatever they wanted about some medicine they cooked up in their basements. The FDA was formed in 1906 to make sure that foods and medicines were not contaminated with obviously dangerous substances. In 1938, the FDA also began policing companies who made false claims about the effectiveness of their products. By the 1960s, the FDA required that new drugs actually prove their safety and effectiveness before they could be sold in the United States. New laws also prevented drug companies from even advertising their products as good for any particular disease until the drug had been tested and approved by the FDA for that particular disease.

At the same time, the process for approving a certain drug for a certain disease became more and more strict. This meant more research was necessary, increasing both the delay and the expense in bringing new drugs to the public. This added expense meant that drug companies chose to spend their limited resources on the drugs most likely to sell the best: drugs that a substantial fraction of adults would take every day for lifelong conditions like diabetes, high blood pressure, and depression. This meant less money was spent researching drugs that are taken only for a short period of time, like antibiotics.

When you test a drug, you get the most reliable results by testing it on a group of people who are as similar to each other as possible. It’s easiest to do this with adults. Children vary widely, from infancy through childhood through teen years. So although many new drugs have been approved since the 1960s, by the 1990s only 20% of them had been tested in children. In 1994 the FDA made rules to encourage drug companies to test their medicines in children. The courts said the FDA didn’t possess the power to do that, so the “FDA Pediatric Rule” was discontinued. More recently, Congress has been trying to accomplish the same thing.

In the meantime, the bad news is that relatively few drugs have been well-tested particularly for children. The good news is that for most drugs, the fact that they work in adults seems to be good evidence that they are effective and safe for children. Everyday drugs like acetaminophen and ibuprofen are not “approved for children” under the age of 2, which is why their labels say “consult your physician” rather than giving a dose. The approval process is so difficult that few of these old drugs will ever be officially “approved for children,” but decades of clinical experience shows that they can be used in children. So don’t be alarmed just because a drug label says that it’s not approved for children. Ask us about that drug, and we can tell you what’s known about its safety in children, besides the fact that it’s not officially FDA approved.