Classic toddler asthma signs easily overlooked

Yes it's true that even your humble RT and lifelong asthmatic can over look the classic signs of asthma.  My 3 YO HM woke at 2:30 in the morning, was agitated, coughing, and was annoying her father.  He even yelled at her, because he thought she was simply caught in that flux between sleep and reality.

He finally set her back in bed and decided she'd eventually fall asleep.  He hopped into his own bed, and his wife said, "Did you give her her pulmicort before bed last night.  Sometimes she has asthma when she doesn't get it."

Bingo!  He could have slapped himself up alongside the head.  He carried the little girl to the living room, set her in the recliner, prepared a breathing treatment with pulmicort and ventolin, and gave it to her by blowby.  Within minutes her breathing was easy and she was sound asleep.  

He set her back in bed and not a peep was heard the rest of the night.  This was a perfect real life example of how even the most expert of asthma experts can overlook the classic signs of asthma.

 It's a also a quintessential example of how important it is that everyone responsible for a child know about the signs of asthma.  When one person misses the signs, perhaps the other will pick up on them.  

I suppose it's also a classic example of the importance of good teamwork.  Regardless, she is doing great today, that little asthma girl.  No longer will we be able to skip a dose of pulmicort.  

My 3 YO daughter's second asthma attack

So my reserved 3 YO daughter was fine when I came home from work last night, yet right around bed time she started coughing, retracting and with my stethoscope I heart inspiratory and experiatory wheezes.  She was tight and her words were short and choppy. 

I gave her a treatment.  It benefited her, yet she was still tight with wheezes.  I had a distinct feeling it was going to be a long night.  An hour later she was distinctly bad again and I gave another treatment.  She fell asleep in my arms, and when I set her in bed he head bobbed up and down on the pillow from her bodies effort to suck in air. 

Remembering my experience sitting up all night suffering from asthma and my parents not realizing what it was, I didn't want my daughter to go through the same thing.  So I didn't think I'd fall asleep.  Yet I must have.  At 11:30 I was awake and heard no coughing.  For a moment I though we had made the right decision not to go to the ER.  Yet then the coughing started.  Then...

"Mommy and Daddy," she yelled in a panicked voice.  I picked her up and she was unhappy I was around.  She was agitated.  She didn't know what she wanted.  She was retracting and audibly wheezing.  It was an easy call.  My wife got out of bed, snuggled our daughter in the recliner, and we made the decision it was time to go in for another steroid shot.

This time one of our regular doctors was working.  She was great. Here's what she charted:

child tends to have wheezing and over the past few weeks has been wheezing more frequently and was on oral steroids at one point.  over the past 2 nights she has been wheezing to the point of requiring breathing txs at home.  tonight she took pulmicort for the first time and this seemed to make the wheezing worse.  mom brought in for further eval. due to her sob.  dad has a hx of severe asthma and is a resp therapist at the hospital here. FREQUENT NONPRODUCTIVE COUGH, DIFFICULTY BREATHING.  Seen by pediatrician earlier in day for same reason.  active/playful/smiles, age appropriate attention, good eye contact, no apparent distress, not irritable, not lethargic Temperature: 98.6, Heart Rate: 140, Respiratory Rate: 48, Pulse Oximetry: 97, Weight: 28 (unable to get vitals previous visit).  x-ray normal.  child given 2 xopenex nebs upon arrival and decadron im.  after third neb child was much improved.  she had a p ox of 97% on ra and was talking well.  retractions were gone.  will give prelone for home and discussed close follow up.  scripts:  Prednisolone (Prelone) 15 Mg/5 Ml Syp  25 Mg OR DAILY (note:  Errors are the doctors.  I did not correct grammatical errors).

This doctor is one of our regulars and she also has kids, so that helped a great deal.  My daughter must have sensed she was a good person, because she actually let her assess her.  This just goes to show that if you're good in your approach you can even get the most reserved kids to cooperate in the ER.  Common sense, you know, goes a long way.

The doctor also said that decadron has a tendency to last longer than solumedrol, sometimes up to three days.  She said that's why she prefers to use it with kids, especially kids who don't like to take nasty taking prednisone pills. 

At 3 a.m. my wife arrived home and she went to bed while I stayed up with my sweety.  HM was hyped up from all the medicine and was marching around the living room chanting a hundred words a minute.  Finally she asked me if I'd lay down with her, and before my head hit the pillow next to hers she was sound asleep. 

Today she was back to normal.  This was a much better ER experience than three weeks ago.  It shows how smooth things can go when you respect the parent.  Or, it shows how smooth things can go when the parents and doctor use common sense.

My 3 YO daughter's first asthma attack

So I picked up my daughter's medical records today from her ER visit On Nov. 27.  My wife took her -- my little reserved 3-year-old -- to the ER that day because of an exacerbation of asthma.  It was clear to me it was asthma, although I can tell from what the arrogant and condescending doctor wrote she didn't necessarily agree.

Here's what the doctor wrote on the chart::

"Child has had cough and difficulty breathing for two weeks.  Mother is RN and father Respiratory therapist and they have been giving her xopenex and albuterol every two hours at home since 0300 today.  She has not been diagnosed with asthma.  Mother states "she hates people." Mother has called their pediatrician and report was called to ED to avoid drawing blood on the child.

"Duoneb times two and worked to get cooperation to take steroid.  After second neb still with wheeze inspiratory (scant) and full exp cycle.  CXR neg.  Solumedrol given IM and RX pediapred and atrovent for home.  Mom is RN and Dad is resp therapist.  They have home nebulizer and expressed preference to continue treatment at home.

Responds well to DuoNeb howevr still wheezing.  Added steroid and to send home on Albuterol and Atrovent neb and PO Pediapred.

I think it's pretty clear the doctor was irritated my daughters pediatrician called with recommendations on how to treat my daughter.   It was actually more us than our pediatrician.  My wife and I are minimalists, and we know by our clinical experience that ER doctors have to order a bunch of stuff just to cover their butts. 

Figuring my daughter's asthma is similar to mine, she didn't need a bunch of labs and an IV.  All she needed was the steroids.  I also had this distinct feeling this doctor wanted to admit my daughter too.  The doctor was also not one of our regular doctors, which may explain the poor attitude. 

And guess what.  The steroids worked great.

Related links:  My daughter's asthma attack and the arrogant doctor

My daughter's asthma attack, and the arrogant doctor

My daughter, Mrs. L, all three years of her, was introduced to the asthma beast this past week.  She required a breathing treatment a few weeks ago and it worked like a charm.  Yet last weekend the asthma beast struck with a vengeance.

She woke up in the night coughing.  I gave her a breathing treatment and it seemed to work.  Yet the next night she was up crying.  I entered her room and she was sitting up in bed.  It didn't take much convincing for her to let me carry her to the living room.

The nebulizer -- the community nebulizer for my family -- was already set up next to the recliner I set in with her.  I grabbed an amp of Albuterol and squirted it in, and revved the machine to life.  You can always tell when a kid benefits from a bronchodilator because she sits through it. 

Yet the treatment did little to relieve her coughing.  I sat up with her for an hour watching some old cartoon I can't even recall what it was.  Quite frankly I don't think she did either.  In fact, we didn't even have the sound on.  The vision of a toon was all that was needed to placate my daughter.

I was emotionally into this, because I could remember vividly sitting up in bed all night long when I was a kid not being able to breathe, and my parents had no clue.  It's not like they didn't care, they just didn't know.  I didn't want my child to have that scar, so I doted her.

The next day, Sunday, my wife or I had to give her a breathing treatment every few hours.  She probably could have used one more frequently.  Yet it was enough for us to realize she needed more than bronchodilators:  she needed systemic steroids.

Her doctor was out of town, so that posed a problem.  If she was in town we would have called her and she would have written a script for prednisone.  She knows me and my wife.  She knows I'm an RT and a lifelong asthmatic.  She knows we have a pharmacy here and everything except steroids to keep an asthmatic full of fresh air.  Yet she was out of town.

Dr. B. is a new doctor and I've worked with her enough to be impressed with her.  Yet she said she wasn't familiar with Mrs. L enough to just prescribe something over the phone.  So she recommended we take her to the ER. 

This posed a dilemma. Surely we had no problem taking her to the ER, but my wife and I both know that a trip to the doctor's office usually results in an assessment and a quit treatment of the cause of the problem.  Then you go home and that's that.  You get better. 

Yet if you go to the ER they have to do a bunch of stuff just to cover the butt of the doctor.  Labs will be drawn, an x-ray will be given, and an IV will be put in.  We mentioned this to Dr. B. and she said she'd call the ER doctor with her recommendation.

Great!  Or so we though.  The ER doctor was pissed that Dr. B called her.  The ER doctor was condescending and arrogant to my wife.  She said something like, "It doesn't matter what your doctor said.  I'm here and I'm assessing your daughter.  I have to do what I think is needed.  Dr. B. is not here."

My wife said she wanted to walk out the door right there.  If her daughter didn't need the steroids right now that's what she would have done.  And this is the hospital I work at.  The nurses tried to take a pulse ox on my daughter's food, and my daughter said, "Go away!  Leave me alone!"

My wife said, "Why don't you guys leave and I'll get a pulse on on her finger."

Yet they insisted on getting a pulse ox on her foot.  Here my daughter, my shy daughter who is deathly afraid of people, has five nurses holding her down to get a pulse ox.  My daughter cried and fought vehemently. Good for her.  I wish she would have fought harder.

The doctor peeked her head in at this time and said, "Well, she's crying.  So she must be breathing fine."  My wife responded, "Wait for her to stop crying and you'll see she's retracting and her fingers are blue."

The doctor left.  The nurses left.  My wife got a pulse ox reading in about 2 seconds once they were out of the room.  My daughters oxygen saturation of 82%.  That's not good.  And this all happened in triage.  When she finally got to her room my wife had to fight off the impulse of the doctor to insist an IV and labs be drawn.  Yet my wife stubbornly resisted.  I am proud of her.  "All she needs is steroids," my wife insisted.

The doctor was pissed.  She listened to Mrs. L. with her stethoscope.  She said, "She's wheezing.  She has inspiratory and expiratory wheezes.  Inspiratory wheezes are the worse kind.  You should have come in sooner.  If you need to give treatments every two hours you need to come to the ER."

My wife rebutted her comment:  "We did come to the ER."  And she probably thought, "You dumbF#$@!"  I know my wife thought that because I know my wife.  Yet I bet that doctor would doubt me. 

The doctor prescribed a steroid drink, and my wife said Mrs. L. won't drink it.  The doctor said, "We'll mix it up in a pop and she won't even know the difference."  My wife said, "She's never had a pop in her life, so she probably won't even know what pop is.  She won't drink that."

So you can see this made for an interesting visit.  Finally my wife said, "She's not going to drink this stuff.  Let's just give her the shot and get it over with."  Five nurses held Mrs. L. down, and she didn't even fight.  Later that night she said to me at home, "Daddy, I got a shot and I didn't even cry."  She smiled.  She smiled because she knew the shot made her better. 

Yet. Steroids work on asthmatics in my family.  We don't need labs and xrays and IVs and all that unnecessary stuff.  Surely if the steroids didn't work you can look for something else. 

My wife said the nurses were great.  Later I talked to one of these nurses about that doctor, and she said the doctor has to cover her butt.  Yet I said, "A doctor should also respect the wishes of the parent.  A parent knows her child more than a doctor does.  Not to disrespect the wisdom of that doctor, yet she really needs to respect the parents, especially when the parents are a nurse, and an RT who is a lifelong asthmatic.  It's not like there's no experience here.  We're not your typical ignorant parents."

This is exactly the reason I never go to the ER when my asthma acts up.  The last time I was an ER patient they took me off my theophylline and almost killed me.  Eight days later a different doctor put me back on my theophylline and I miraculously got better.  So if you have asthma, and you know what works for you, and the doctor wants to do something totally different, who's right? 

That steroid shot gave my daughter almost instant relief.  She ran around the living room that night the way I'm accustomed to seeing her, all happy and cheerful.  In the end, that's what's most important.  As far as the rotten ER doctor, she was a rental doctor and both my wife and Dr.B. reported her arrogance to the powers that be.

Body for life and the greatest vacation ever

So the first time I worked out was in 1998, and by the time I met my wife at my work in 2000 I had gained it all back, or at least most of it. I was a bloated 210 pounds and feeling sluggish. Although that cute, intelligent nursing student still fell for me.

I tried to continue to workout I did a few years earlier, but I kept slipping. That was when my wife talked me into doing the body-for-life program. This is a program where you eat a carb and a protein every 2-3 hours, and you work out every day. The great part about this program is you get to take one day off every week where you don't work out and you can eat whatever you want.

It sounded kind of stupid at first (of course I though any exercise was stupid before I lost weight a few years earlier), but I ultimately agreed to try it.

This first time I tried the body for life to get into shape was during the run-up to my Wedding which was to be on May 18, 2002. For this event, I ended up losing 35 pounds in less than 12 weeks. It was a major success. I went from 119 to 180. Once again I was feeling trim.

So as I look over at our wedding picture, I'm looking great, and so is my wife. The problem with that diet was that after my wedding we went on a four day cruise where we left Miami on day #1, went to Key west, Cozumel, and then back to Miami. This was the best vacation of my life; of both of our lives.

One of the neat things about this cruise is everything was all inclusive, including the food. And food there was lots of it. There was food everywhere. There were buffets that were open 24-7, and then there were many restaurants, and also places for fancy dining.

I remember getting up one day and eating breakfast, having brunch and then lunch, and then lunch-dinner, then snack, then dinner, then after dinner snacks, then snack again, then snack again, and then midnight meal, and then getting back to our rooms and ordering room service just because it was available and it was free.

At about 1:30 a.m. my wife and I were startled by the sound of the door bell. Barely able to muster the strength, I got up and opened the door. "Yes!" I mumbled. A well groomed guy was carrying bags. "You ordered room service?"

"Ah!" I mumbled again. "Yeah, I guess we did." I shut the door, and turned to my wife, "Get up, honey! It's time to eat again."

She smiled. For the next hour we ate.

By the end of this glorious vacation I had gained 10 pounds. In retrospect, I would do it all over again. Only, if I did, I would get down to 170 pounds instead of 180.

Within the next KK was in the oven, and while I started a workout program when we got pregnant, I ended up gaining weight right with her. Once again both my wife and I succeeded in losing weight, and failed at maintaining it.

I actually remember thinking once during the course of this diet, as I was feeling awesome and in the best shape of my life, why anyone would want to be out of shape. Well, my wife and I were leaning, even someone who knows how to lose weight, and is aware that losing weight is needed, struggle in this effect.

Hmmmm, I wonder how many people have that problem? There's this old saying that eating is the hardest addiction to get over, because -- unlike cigarettes -- you literally NEED food.

Body for life and the greatest vacation ever

The first time I did the bodyforlife program to lose weight and get into shape was during the run-up to my Wedding which was to be on May 18, 2002. For this event, I ended up losing 35 pounds in less than 12 weeks. It was a major success. I went from 215 to 180.

So as I look over at our wedding picture, I'm looking great, and so is my wife. The problem with that diet was that after my wedding we went on a four day cruise where we left Miami on day #1, went to Key west, Cozumel, and then back to Miami. This was the best vacation of my life; of both of our lives.

One of the neat things about this cruise is everything was all inclusive, including the food. And food there was lots of it. There was food everywhere. There were buffets that were open 24-7, and then there were many restaurants, and also places for fancy dining.

I remember getting up one day and eating breakfast, having brunch and then lunch, and then lunch-dinner, then snack, then dinner, then after dinner snacks, then snack again, then snack again, and then midnight meal, and then getting back to our rooms and ordering room service just because it was available and it was free.

At about 1:30 a.m. my wife and I were startled by the sound of the door bell. Barely able to muster the strength, I got up and opened the door. "Yes!" I mumbled. A well groomed guy was carrying bags. "You ordered room service?"

"Ah!" I mumbled again. "Yeah, I guess we did." I shut the door, and turned to my wife, "Get up, honey! It's time to eat again."

She smiled. For the next hour we ate.

By the end of this glorious vacation I had gained 10 pounds. In retrospect, I would do it all over again. Only, if I did, I would get down to 170 pounds instead of 180.