Ep 144: Strategies for Alleviating Anxiety in the Operating Room, with Dr Nina Shapiro, Pediatric ENT

Dr. Nina Shapiro, a pediatric ENT, discusses the most common procedures and visits in her field, including ear infections and sleep disorders. She also addresses the anxiety that families may have about procedures and surgeries. She shares strategies for explaining procedures to children and discusses the use of sedatives and iPads to alleviate anxiety in the operating room. In this conversation, Dr Shapiro discusses the risks and misconceptions surrounding anesthesia in children.  They also discuss the use of ear tubes and swimming, with Dr. Shapiro explaining that most children with ear tubes can swim without any limitations. The conversation concludes with a discussion on the importance of providing detailed information to children and families to alleviate anxiety and improve the surgical experience.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

Follow her on Instagram: @AskDrJessica
Subscribe to her YouTube channel! Ask Dr Jessica
Subscribe to this podcast: Ask Dr Jessica
Subscribe to her mailing list: www.askdrjessicamd.com

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody. I'm Dr Jessica Hochman, pediatrician and mom of three. On this podcast, I like to talk about various pediatric health topics, sharing my knowledge, not only as a doctor, but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. This week's guest is the phenomenal Dr Nina Shapiro. Dr Shapiro is a pediatric ear, nose and throat specialist, and she practices in Santa Monica, California. On today's episode, we are talking about what parents need to know about common surgeries she performs like placing ear tubes and tonsillectomies. This is an episode to help prepare kids and parents if they are considering one of these common procedures. Thank you so much for listening, and as a reminder, if you're enjoying this podcast, please help show your support and leave a five star review and share this episode. Thank you so much. Dr. Nina Shapiro, I'm so happy to have you back on the podcast. You're such a mentor of mine, so it's always an honor to get a chance to talk to you. Well, it's so great to be here. Thanks for having me back. Always great to see you. So tell everybody what kind of a doctor are you? So I am a pediatric ear nose and throat specialist. So I'm an ear nose and throat doctor who takes care of just children. I've been doing that for a long time. I was at UCLA for about 25 years, and I've been out in private practice for the last almost two years. Amazing. And what are the most common procedures and visits that you have as a pediatric anti So the most common thing that I see is actually the most common thing that pediatricians see in their office. So the most common thing that pediatricians see in their office is a child with an earache or ear pain. Sometimes it's an ear infection, sometimes it's not, but the most common thing that I see and treat are children who've had not just an ear infection, but multiple ear infections, or ear infections that don't get better, kids who have fluid behind their ears. So that's the most common thing that I see. The second most common thing that I see is kids who have issues with sleeping so snoring, Sleep Disorder, breathing, big tonsils, big adenoids, stuffy nose all day, difficulty breathing. So those are the two biggies that all pediatric EMTs see pretty much all day. And do you find when you see families with these issues that a number of them result in a procedure or a surgery. It depends, you know, I see a lot of families where they, you know, maybe it's a child who's had like, two or three ear infections, but they're getting better. And that's certainly a child where I'd say, Well, you know, let's give it some time. They'll probably, you know, especially headed towards the summer months, you know, maybe they'll get better. You know, when the cold season goes, a lot of these kids, the ear infections, especially, are tied to colds. So, you know, sometimes we start to see a little bit of a break. So, so we'll see so a lot of the kids do need procedures, because, again, they're coming to see me after they've seen their pediatrician multiple times, but some of them, it's just a matter of watchful waiting, where we try some other medications or other options to just, you know, see if they'll get better on their own. You know, it's interesting, because I find parents either cannot wait to see a specialist, and then I find there are some patients that are really nervous to see a specialist, because they're nervous that they'll be recommended to get procedures or to have something more involved medically. Do you find that? Do you find that there are a number of families that are anxious to see a specialist? There are some families who come in and say, When can we have the surgery? Can we do it tomorrow? We're ready. And those are families that obviously have given us some thought. And you know, I'm sure they've had discussions with their pediatrician, and maybe some friends who've kids have been through it. And then I again, Yeah, same thing. I have families where they say, you know, we want to do everything possible to avoid any sort of surgery. And even, you know, a lot of families don't, are very, sort of reluctant to have medication for their kids. So, you know, really, really the range, you know, again, some families come in, when can we do it? We're on it, ready to sign up. We're excited. And then some families that are are very reluctant, and oftentimes it's for good reason. I mean, a lot of the families that are wanting the surgery, their kid really needs it, and they're going to do really great. And then the families that reluctant, you know, oftentimes it's because their their child probably doesn't need it, or certainly doesn't need it at the time that I see them, don't you find there's so much gray zone in medicine, it's so true, that oftentimes there's not a clear cut answer right away. Most of the time there's not, or a lot of you're absolutely right. A lot of the times, you know, even when it comes to, does a child need antibiotics for an infection? Well, you know, is it a virus? Is it going to get better on its own? Did it get better because of the antibiotics or just because, you know, for other reasons, there is a lot of gray zone, and especially in what we do in en. T A lot of the time, it's based on quality of life, and that's oftentimes hard to, you know, to put a number on or put a specific data point on when it's an individual child. That's such a good point, especially when I think about ear tubes, and I think about, you know, getting the adenoids removed, it really does come down. It really does come down to a quality of life. But I have to say that those procedures, in particular, the feedback that I get from families when it really is indicated there's so much happier on the other end. Oh, my God. I mean especially ear tubes, which is my, you know, it's, it's one of my favorite procedures, because it's, it's very safe. There's very, you know, the nothing is zero, but it's extremely low risk. It takes a few minutes, literally, like a five minute procedure, and you are making a new child for this family, and oftentimes for the better. So this could be a child who's around one year, year and a half, and they're not walking, they're not talking, and then a week or two later, you have a child who's walking and talking after this five minute operation. So it's almost miraculous. That's one of my favorite things that to do. I have to say, even getting the adenoids out, I find parents are so happy because they have a child that's not sleeping that well, they take the adenoids out, and all of a sudden they have this child that's sleeping soundly, and that translates to improved behavior during the day, which makes everybody happier. Yeah, so I can't say that for all surgeries that I see kids get where there's such a clear benefit on the other end, but I have to say what you do must feel really good. It's, yeah, it's great. I love what I do. And again, it's, I love to see how it helps the kids and the families. Yeah, sleeping too, like any sort of breathing issue during sleep, when they're really noisy and they're struggling, you don't realize how much impact that has on their day, on their day to day, behavior, how they feel at school, how they feel waking up in the morning, even their their appetites and their interest in food and sports, it all improves after you know, they can breathe and sleep at night. And here, it's amazing. I mean, for me, I feel like it's such a it's such a benefit when you talk to families who have had and been through surgery, and they are pleased on the other end, because it's not a good feeling when you do something that's involved, like a surgery, and the families aren't sure if it really improved their symptoms. So how nice to be a pediatric ENT, I recommend it for those of you listening who are thinking about pediatricians are great too, and pediatrics is an amazing field, but within that pediatric EMT is recommended, yeah. I mean, I talked to my husband's an adult doctor, and sometimes I talked to him about back surgeries, for example, or knee surgeries. And oftentimes families aren't really sure on the other end, if it was really beneficial. But I like recoveries too. It's not like, you know, they walk out and they feel great, takes a while to even see if it helps. So I'm just so curious, from you as a surgeon, what do you do to help kids feel more comfortable and less anxious before surgery? So, you know, a lot of it really starts during the office visit some kids, you know, a lot of it is just based on their age and their interest and their understanding. Some kids hear the conversation and they really hear what I'm talking about with, with the family in the office itself, and I can sort of see that they're starting to get a little bit uncomfortable. That tends to be older kids, meaning kids maybe second third grade, and over maybe they've heard the word surgery or procedure, or tonsillectomy or ear surgery. So those kids, I try to get that conversation going in the office with them, and I get a sense oftentimes to the child, and I'll talk to them, because they'll say, I don't want to have, you know, some of them will just say, I don't want to have my tonsils out, or I don't want to have my adenoids out, scared, and then we can really start working through. Well, what are you scared about? What about it scares you? And it really is very age dependent. So some kids, you know, at a certain age, most ages, actually over age, I'd say four, are afraid of getting a shot. They associate a hospital, a procedure, with a shot. So we can work through that. Because actually, the way we do anesthesia for kids, they don't get a shot. So we can wipe that off the table. You're not going to get a shot. We don't give shots for anesthesia. So done. Okay, great. What else are you nervous about? And then I just sort of go through everything. I don't want to have something taken from me that's off oftentimes. And I always tell that to parents when they talk to kids, kids and adults tend to not like body parts taken from them for good reason. So how can we reframe that? First of all, the way that a lot of us do tonsillectomy and adenoidectomy is a shaving technique, so we don't actually take out the structure itself. We just reduce it and shrink it so just to reassure them, nothing's going to be taken from you. So that often makes them feel better. And then. And older kids are worried about the anesthesia. They really understand the concept of anesthesia, and that tends to be starting at about age 12 or so, and what they're afraid of is not falling asleep during the anesthesia, waking up during the anesthesia, or not waking up after the anesthesia. Those are the three things. And we what we kind of work through all of those, and why anesthesia is very safe, and how they're so closely monitored, and how we can tell that they are asleep enough and awake enough. And just sort of, it's not just sort of this random, you know, getting a mallet on the head and going off to sleep and then hoping they wake up. We just sort of work through that. Some kids are just afraid about, I want my mommy or daddy or parent or somebody to be with me. They're very afraid of separation. And that actually starts pretty early. That's probably the first fear and and then we can work through that. Well, you know, they'll be right there for you, they'll be up there. They're not really going to be away from you. And as soon as you're awake, you can give, you know, an ice pop with with your parents. So, you know, it really is very age dependent, and that's really where I start in the office. But a lot of family, a lot of kids are don't even know what I'm talking about, and have zero interest in the visit. Once I'm done with the exam, they may be reading their book or playing on a on a screen. So then it just becomes the parents. But that's what I do in the office. If I sense that the child is already developing some anxiety, I think where what we have in common, because we work with kids, we have to help the child, but we also have to help the parent, yes, yes, and that's where the conversation goes, because, again, most kids don't voice any sort of concern or interest during the cert, during the the office visit. Then the parents, sometimes it's a phone call, sometimes it's it's a conversation at the visit as far as what to prepare for their child, but you know, again, obviously what to prepare for themselves as far as what to expect leading up to the surgery. So what I usually tell the parents is, I Well, and a lot of them will literally say this, walk me through it, you know, give me the play by play of what's going to happen on the day and what's going to happen afterwards. So then we really just go step by step. Here's where the parking lot is, here's where you're going to go, here's what's going to happen here, you know, literally walking them so they can sort of visualize the entire experience as much as I can, what to expect, you know, including everything with, you know, they're going to get a little gown, maybe, or a little, you know, a little outfit to wear, and they're going to get some stickers and and then also to sort of not paint it as this rosy, perfect spa day that, you know is going to be amazing, that you know, most kids wake up crying from anesthesia, and that's called emergence agitation, or emergence delirium. We see it in over 50% of children, so it's a really, really high number. And I think families who know to expect that it's kind of like a night terror. A lot of it is just their reaction to a very brief anesthetic. And that's normal. It doesn't we're not worried about it. You shouldn't be worried about it. You can worry about it, but your child will get through it, but just something to expect afterwards. So I really try to give them as much detail as I can. And then a lot of parents will ask me, What do I tell my child? Because some parents, over the years have told their child nothing. They just say they're going to the doctors and surprise, and especially if it's something like a tonsillectomy, where there is some discomfort afterwards, I don't typically recommend that. But again, like for the young kids, what I tell the parents is kind of like, you know, when you say, you know, when your child turns four, they should have four kids at their birthday party, you know, five. I mean, we never do that. None of us do that, but we all tell people that's a good thing to do, right to minimize the overwhelm. So what I usually say is like, if you have a four year old, tell them four days or fewer before the surgery that it you know that something is going to happen. Don't give them 234, weeks of lead time and prep and books and all that kind of stuff. Less is more when it comes to preparation, because they are it, they are going to be anxious. So just a few days before, and again, a lot of kids get sick, and so it has to be rescheduled, so then you have to do the whole thing again. So, you know, just a few days before. You know, I think that's so smart, is I do believe in telling kids ahead of time, because I feel like if they come to the office, for example, to get their vaccinations, and the parents haven't given them notice, they start to not trust their visit here. They're upset. Sometimes it works well, but a lot of times, kids are more anxious when they're surprised. So I do like kids going ahead of time, but if they know too far in advance, it can work against us. For example, I had a kid today this morning, who got a finger poke. We checked their iron status, and the mom told me, his friend told him two months ago about the finger poke and how much it hurts, and she said he's been worrying for the last two months as a five year old. So to your point, I like the day. I really like the rule of thumb as how many years old they are is how many days ahead of time they should know about it, or even less than that, like, you know, maybe two days in advance. You know, if they have something at school, a big thing on a Monday, and the surgeries on Thursday, tell them on Tuesday after their big, you know, school thing. So that's one thing. And then you know what I like to say, and this is more for the younger kids, meaning, like preschool age, you're gonna go visit that doctor, Shapiro. Do you remember her? No, usually, just fine. See me, you know, it's not, I'm not their regular pediatrician. Maybe they'll remember me, but it's not going to be in her office. It's going to be in a different place, and it's a different kind of visit. It's not a regular doctor visit. And then what I recommend is that they tell them that whatever the issue is, whether it's ears or nose or throat or breathing, that it's going to that Dr Shapiro is going to help fix it. I'm not going to take anything, and I'm not going to put anything they don't like, even, you know, the tubes which are in their ears. You know, the idea of putting something in their bodies is a little terrifying, unless they want to get their ears pierced when they're little. Older. But in general, you know, fixing is a good word to use. But a lot of these kids, especially if they're coming in for snoring sleep issues, they think they're fine. They're not necessarily aware that they are having, you know, horrible sleep quality and horrible behaviors and focus issues, but you know, to whatever extent they will appreciate maybe there's one thing that bothers them about their tonsils or their adenoids that you know they that ducks going to help fix it. Then sometimes the kids ask the parents questions, and I let them sort of go with that, well, is it going to hurt? That's often a very reasonable question. Well, you're not going to feel anything. But then afterwards, I also think it's really important to be honest with kids, to say you're going to have a sore throat. I think it's fine to know that a lot of some of the kids that we take out their tonsils, they've had a lot of sore throats. So that's a little easier, because then we can say, well, you remember what it's like to have that sore throat? I remember you took some maybe medicine to make it feel better, and you rested and you had some soup and some ice cream. Well, it's going to be like that, but you're not going to be sick so, but you are going to have a sore throat, and you can do a lot of different things to make your throat feel better, and then hopefully you won't get any sore throats after this. So, you know, I think they, they do need to know it's they're going to have a little soreness and and most kids are okay with that. Actually, it's, it's the needles that they they're really afraid of, you know, like a shot or a blood test. We're getting poked, although some kids have some other issues that, you know, we had a child recently who had a really intense concern about band aids. You're like band aids. And some kids, you know, they don't like it. It hurts when you take their band aids off, but during surgery, we have to put some stickers on for monitors. And so she was not thrilled when you know her throat was fine after the surgery, but she didn't want to take get the monitors off. And that was a whole, a little bit of a issue. So it's so interesting. How many fears there are, yeah, yeah, yeah. A lot of kids are just afraid of leaving their parents. I think that's a very reasonable fear, especially when it's not like their teachers or people that they know on a regular basis. A lot of the people that that I work with in the operating room, they're meeting for the first time. So that's that's a little bit scary. So what do you guys do? How do you tell the operating staff to make sure kids are as comfortable as possible? Do they have any tricks? Yes, there are a couple things we do. So actually, back at UCLA, we did a study, what are the best ways to relieve perioperative anxiety in children? And so we looked at three things. We looked at a parent coming into the room with them until they go to sleep. We looked at watching a show on an iPad, we looked at playing a game on an iPad, and we looked at giving an oral sedative. So which do you think was the best I would say the parent being in the room. The worst. Really, that was the worst, and we had ways of objectively measuring very operative anxiety. So let me be honest, I think, I think what I would like probably getting a sedative. Yes. So we do, we do two things. Actually, we do three. So we give a sedative to the child, very safe, very low dose, and it doesn't put them to sleep. It just takes the edge off. It helps with separation, and it also helps it causes a little bit of what's called retrograde amnesia, so they it helps them forget the separation experience. So we give a sedative. We do recommend for children over I guess two nowadays, if they have an iPad, especially if they're not used to using an iPad to bring one, because we let the child bring the iPad into the operating room with them. And so the number one way to relieve perioperative anxiety is to play a game on the iPad above better than a sedative, although we do both. And the reason for that is there's something called perceived personal control. And when you're playing a game actively, you have a sense of control. And you know when it when you're in the operating room setting and you feel like you have a loss of control, especially if you're five years old, that's a way of of giving yourself some control. So, so we tell them to bring an iPad where, you know, the nurses are and doctors are very nice and very you know, we give coloring paper, we give crayons, we you know, we give them little toys to play with. We give them little stuffed animals like, and here's a new tool. Here's a present from us, a little stuffed animal. So we try to make it, you know, really pleasant and light, certainly no needles until after they're asleep. It sounds like you guys are really thoughtful, yeah. And it really makes it you know, most of the kids, you know, by my you know they're waving to their parents when they're walking, but when we you know they're wheeling back to the room because, you know, we try to make it fun. You know, we get we let them. You know, the operating room doors have, like a button that you push on the side wall. So one of us will be standing there, and we'll have the child say, you know, Open Sesame, and the door opens magically. So that's their sense of like they have some control over their over their world. If they don't have an iPad, we have screens, like, pull down screens in the operating room. So if they don't have a screen, we'll say, Well, what show do you like to watch? And we'll put on that show. So while they're, you know, breathing the anesthetic, they can watch, you know, blue tends to be bluey these days. Or what you're saying actually is making so much sense to me as we're talking, as I'm listening to you talk, because I think my son would love to sign up for a procedure. If you some of them say, can I come again? This was great. And then in the recovery room, because it's such a short procedure, you know, we give a popsicle or an ice cream or, you know, we make it fun. A lot of them don't want to leave. But, you know, I would tell you on my end the question that I get a lot from parents when we talk about the possibility of their kid getting ear tubes or having a tonsillectomy, is the anesthesia, the parents get nervous that anesthesia will carry some risk, right? So have you, I'm just curious, in all your time doing these procedures, have you noticed risks from anesthesia in children? So you know that, as you know, sort of the line is, and this is a very true thing to say, is that nothing is without risk, right? So, you know, anesthetics included. That said, a lot of people worry about, well, how do I my child has never had anesthesia? How do I know if they're allergic to it? I get that question a lot. And the type of medication that we give is not the kind of medication that leads to allergic responses. It's not like an antibiotic or other types of medication, so the allergy is not an issue. There are some rare entities that tend to run in families where the child is at higher risk for an anesthetic complication, and if that's the case, we probably won't do it in an outpatient surgery center and or we can get them tested for a very, very, very rare, very specific entity that's associated with high risk anesthesia. But the anesthetics that we use are very, very safe. They're very volatile, meaning that they're very short acting, so most of the anesthetic that we use is inhaled. These are very safe in children. They're very safe in infants, even younger than children. It's been well studied, used for decades. And what's nice again about them is they're very short acting, so they literally Breathe it out of their system and it's gone. It's not lingering or anything like that. And the other thing is, because we have such close monitoring, like we're watching their heart rate, their oxygen, their carbon dioxide, their blood pressure, their everything, really, you know, their EKG, even we can tell very, very specifically how much to give. I mean, obviously a. Lot of it's based on age and weight and size of the child and history of anesthesia in the past, sometimes so but it's very, very, very closely monitored. And one of the, I would say, one of the biggest advancements in pediatric surgery is not, you know, surgical techniques or indications. It's anesthesia. Anesthesia has advanced so dramatically in the past three or four decades that the safety profile is is extraordinarily high. I mean, not to say, you know, we live in Los Angeles, you know, but it's, it is literally safer to have a general anesthesia than to cross some of the streets in Los Angeles, for sure. Well, I think people have a deep seated fear. They have a what I've heard before, somebody has a distant relative from a million years ago where they went under anesthesia, they never woke up. So is this something that you ever seen, or, should I say, like something that is this something that parents should be concerned about with their children? You know, I think it's reasonable to talk about that, because there are some, again, there are these rare and entities. One of them is, is an entity called malignant hyperthermia, which is genetic disorder that one family member has it. Any family member who's undergoing elective surgery does need to be tested for it, because that is a there are ways, and there are anesthetics, to prevent the response to this entity called malignant hyperthermia, which is, you know, it's not malignancy like a cancer, like a tumor, but it's a very dangerous anesthetic reaction that leads to an extraordinarily high fever and other problems with their body. But again, that's such a rare issue, and it's also family knows about families who've had family members with it know that term, that's how rare it is, and they know if someone had it. So that's the one thing. The other thing is, there is an enzyme that people have that breaks down one of the anesthetics, which we actually almost never even use in children, and then some people don't have enough of that enzyme. It's not dangerous. It just means that they'll have a much slower wake up. Doesn't mean that they won't wake up. But again, it's not even an anesthetic that we use, typically in children, it's an anesthetic called succinylcholine, which is a muscle relaxant. Other than that, you know, when it's an adult who had some horrible anesthetic event, very likely it was not the anesthesia. They probably had some terrible complication, whether it was a heart attack during surgery or a stroke or a blood clot or some or some other primary medical issue that led to their quote, unquote, not waking up. But the likelihood of a pure anesthetic untoward reaction is so, so, so extraordinarily rare. I have to say that I can't think of a single example in my time as a pediatrician where a patient has had an issue from anesthesia in terms of not waking up from the anesthesia. No, no. Yeah. And, and now, and also, you know, again, like, because of the teenagers that I take care of, and, you know, the middle school age kids, you know, they will ask me, Well, what if I wake up during, you know, that's an interesting question. How will you know if I'm asleep? How do you know when to start? That's a great question, too. And you know, again, we can tell if, you know, just by very, very subtle changes. You know, if their heart rate goes up just a tiny, tiny bit, it doesn't mean they're awake, but we know that maybe they need a little more of the anesthesia, you know, before we go. So we have so many ways of telling, not only before we start, but during the entire operation, that they are asleep enough, not too asleep, but just asleep enough for us to do our work. And then, you know, again, because these surgeries tend to be pretty short in duration, you know, and I work with very experienced anesthesiologists. They know when to when the child is ready to wake up. And so that's obviously very important, too. We've never had anybody not wake up, God forbid, yeah, but I think that's, it's nice to know that it's very, very low risk, but I think that was really helpful to hear about the malignant hyperthermia, just so that it's on people's radar. Yes, and again, it's, it's, it's something that every family that I've met who's had a family with a family member with malignant hyperthermia knows they have a family member with malignant hyperthermia. It's a very, very specific diagnosis. It's not just that they take a long time to wake up. The other thing that I get asked a lot is, you know, especially, you know, females tend to have a little higher risk of nausea and vomiting after surgery. So I get a lot of those questions like, will my child have a lot of nausea vomiting after what do we do? What can we do to prevent it? The kind of surgeries we do? Um. And children in general, they don't tend to have a lot of that, but we do give medications to prevent it and treat it if necessary. But that's a question I get a lot. What if they throw up? You know, after Yeah, my dog is getting spayed next week, and they gave us a lot of anti medics. Oh, interesting, just in case. Yes, they give her before surgery. So thank you. Thank you so much. Can I give my dog the iPad? That's a good idea. So, and I like what you said about how anesthesia is short acting that it leaves the system pretty quickly after surgery. Because I do think some people worry that there'll be lingering effects of the anesthesia that will stay in the system. No so some of the medications that we give, like we do give medication to prevent nausea, we do give Zofran, which is very similar to what adults get. Something on dansatron is a great medication to prevent nausea. And we give some other medications. We often give something called dexamethasone, which is a steroid. It does help with swelling, it helps prevent nausea and vomiting also, and sort of works with Zofran to minimize that those can stick around for about six hours or so. But the inhaled anesthetics and the intravenous anesthetics that kids get, the inhaled anesthetic is gone in minutes, and the intravenous anesthetic is gone, you know, certainly within an hour or less after the after the procedure. And what about a common concern that I hear from parents with ear tubes is they're worried about their kids and swimming. So is it possible to still be a swimmer and have the tubes in place absolutely. So, you know, kids should swim. I'm a big proponent of learning to swim as young as kids can. And I also really think kids need to learn to go underwater and be comfortable underwater. So we use really small tubes now, and the material is this, you know, surgical plastic, so it kind of repels the water a little bit. So most kids actually don't even need earplugs or headbands for swimming. They can swim. And most kids don't even notice that they have ear tubes. What I usually tell families is, after your child has tubes, let them swim. If the water bothers their ears, they will let you know. The other thing that we can see after water exposure is some kids can get a little local infection, and they'll get some sticky, gooey stuff coming out of the ear. If either of those things happen, which is probably about 5% of kids with tubes, so it's a pretty low number. Those are the kids that I do recommend, either ear plugs or they make these swim headbands. It's kind of like scuba material that that is like, literally, like a headband that covers the ears and that's enough of a water barrier. Those are the kids that do need some water protection, but there's absolutely no reason why a child shouldn't swim with tubes. It's amazing. So the tubes really don't limit them at all. I mean, I usually recommend no swimming for you know, about three days after the tubes are done, just to let everything kind of settle down after that. Yeah, no, they can swim. You can do everything that's really get on an airplane, do everything, no, nothing that limits them. I think that's I think that's helpful, because I think parents assume that their kids would be limited in some way. So that's good to hear. Yeah, no, no. So it sounds like the overall approach you have is just making sure that you talk to the families and the child from the outset, that you walk them through the entire procedure, what it's going to look like from the parking lot through the finish, and that you answer all of their questions, yeah, and I like to, and again, some kids, even really young ones, really want some detail, and I will give them as much detail as they Ask. And I think that's just in general with parents, you know, who have kids who are very curious about health issues or other issues. You know, oftentimes you let the child lead, and you answer their questions without necessarily overwhelming them with information. If they don't want to know too much detail, then that's fine. I think, you know, I think they should know the basics. But if they don't want to know the technique of the tonsillectomy, there's no need to know that. But some of the kids are really interested. What kind of instrument do you use? Do I get stitches? Do I you know that some, some kids have these great questions. So, you know, a lot of it is led by by the child. It makes them feel, you know, involved which they they should be. I'm thinking today, actually, I was thinking about our talk this afternoon, because today I had a patient who had just finished scoliosis surgery, and the mom said it ended up being a great experience. And I said, how, how is it so great? And she said, you know, her child. Was very anxious about getting the surgery, and they walked her through the entire the entire experience. They had them tour the hospital before so that she would know what it looked like. She knew where she was going to get her blood drawn. She knew where she what room she was going to get operated in, so she could totally visualize the experience. And they even had her talk to a family who had been through it before. They matched her up with a kid the same age that had the same exact, same exact surgery. And she told me that she even wanted to see what the Rod looked like that was going to be going on her spine. And they showed her that. And I said, that didn't make you more nervous. And she said, No, I liked it. I wanted to know and it helped me. So I find that fascinating that the more they know, a lot of times it actually makes them feel better. Oh yeah. I mean, a lot of them, a lot of my patients, will say, I want to see the instrument you're going to use. And I think it gives them a sense of it, you know, it's that sense of control without this sort of mystery, you know, this, this child is getting this, you know, steel rod put into her spine. I think it's great that she was able to see what was going to be happening to her. That's That's great. Probably took away the mystery, yeah, and I bet she had a better recovery because of that. Partly they couldn't say, they couldn't say enough praises about their experience, simply because they prepared them ahead of time, right? And I bet the outcome was better because of that, or partly because of that? Yeah, another thing families about is, you know, I always tell them, Well, I'm a worst case scenario kind of gal. So, you know, here are the things that can happen, not really during, because I'm, you know, those are so extraordinarily rare to have any sort of untoward event during, but it's more during the recovery, especially after tonsillectomy. You know, here's the best case scenario and here's the worst case scenario, and very likely it's going to be somewhere in between. But I also like to prepare families, you know, here's what to happen if it's a if it's a question, here's what's to happen if it's an emergency where, you know, it's the middle of the night. You can't really think straight. Here's, you know, I'm giving you sort of, here's the plan for if there is something that is unexpected that happens. So I think that also makes the families feel better knowing that we have a plan if, you know, for the next, you know, week or two of this recovery period so they're not sort of left. Well, what now? What do we do? We can't, you know, find anybody so true. I like a plan. Yes, we do. I like having a plan B. I think it helps. And I have to say, past episode that you were on, you talked in detail about the actual procedure for getting to place. And I've referred many patients to listen to that episode. The feedback I get is I find it really helpful to know exactly what to expect. It helps prepare them for the actual procedure, and they feel better about it. So thank you so much. I'm so lucky that I have you to send my patients to. Oh, thank you. That's how I feel. Thanks. Well, thank you so much for coming on the podcast. It's always my treat to spend time talking to you. Likewise, thanks for having me. Thank you for listening, and I hope you enjoyed this week's episode of Ask Dr Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr Jessica, see you next Monday. You.