The American Academy of Pediatrics recently published its guidelines for how hospitals, and systems of hospitals, should care for injured children. The recommendations have also been endorsed by the relevant organizations of surgeons, emergency physicians, critical care physicians, and children’s hospitals.
Traumatic injuries in children are a huge issue. They are the number one killer of children, accounting for 60% of all deaths up to the age of 18. Thus injuries kill more children than all other causes combined. There is also a large burden of disability later in life for injured children, particularly those with traumatic brain injury. One study from a decade ago estimated this financial burden — initial medical costs, lifetime medical costs, and lost income — at nearly 100 billion dollars.
In spite of the importance of injuries to children’s health care needs, pediatric trauma systems have lagged behind those of adults. There are several reasons for this. For one thing, all the pediatric specialists needed to provide optimal care in fully-equipped PICUs are not available in many places. This is not so much of a problem for adolescents, but it is a major problem for pre-schoolers and infants. Another reason is that, from my perspective, children often seem to be off the radar of governmental and institutional planners. One clear purpose of the AAP publishing these guidelines is to try to change that.
The FDA (Food and Drug Administration) has been battered with another serious incident, this one involving bad batches of the drug heparin (a blood thinner) that originated in China. Nearly a hundred people have died and many others experienced serious reactions after receiving heparin which appears to have been deliberately adulterated with a dangerous (and much cheaper) chemical. Until I read about it I had no idea such a large proportion of our drug manufacturing, like our clothes and our children’s toys, has been outsourced, primarily to China. In fact, now over 80% of the medicines you take, or at least the major ingredients in them, come from abroad. How can we be sure those medicines are safe?
As it turns out, we cannot — assuring the safety of these products is nigh impossible. The FDA is charged with inspecting all factories that make drugs. This was at least manageable when these facilities were in the USA, although staffing cutbacks at the FDA have even made this very difficult. In the case of foreign sites, it is unclear where some of these factories even are, and there are four times as many of them as there were 25 years ago. You can read a good discussion of the FDA’s woes here.
What to do? As one knowlegable person has pointed out, playing “kick the FDA” is not the answer. At its current level of funding, the agency will never have enough inspectors to scour the globe inspecting all these facilities. Increasing this surveilance will cost money. Where should that money come from? Drug manufacturers have reaped the financial benefit of outsourcing — I think it is time they either shoulder a major share of insuring the safety of our medicines, or else bring the manufacturing process back to this county where at least it will be easier to monitor. The recent heparin tragedy shows us what can happen if we do not do this.
All of us have the expectation that our medical records, those personal things about us and our families, are safe from prying eyes. Federal law (HIPAA) protects our privacy and mandates quite strict standards, leading to all those forms you have to sign when you go to the doctor. In these days of the electronic medical record, how safe are those records? As I type this I could, if I so chose, call up on my computer the personal details of every single patient in the hospital. What’s to keep me from doing that? Not much, it turns out, other than my own conscience.
A recent story in the Los Angeles Times, discussed in detail on Dr. Bob Wachter’s excellent blog, shows that, for many people, the temptation to snoop was too much: when Britney Spears was recently in the UCLA hospital, a total of 53 hospital staffers inappropriately looked at her record, 14 of them physicians. Perhaps the bigger scandal is how the miscreants (and all of them knew they were violating both HIPAA and UCLA policy) were treated: none of the doctors were fired, half the nonphysicians were sacked, raising the question of equal treatment for the same crime.
This is not a new problem, of course. I spent much of my career at the Mayo Clinic, an institution well-known for decades for its famous patients, and where the charts of those people were kept well protected. Of course it is relatively easy to guard a physical record, a folder of paper; the electronic medical record is a different matter. Although I am all in favor of the electronic version, this case tells us we must take great pains to secure the data. The case also suggests we don’t treat doctors and nurses the same, and as Dr. Wachter says, that’s not right.
I’ve written before about using e-mail to communicate with your doctor. My own personal physician does this for all of his patients who wish to participate, and it allows me to do things like ask him simple questions or get refills on my prescriptions. It works well for those kinds of things and saves both of us time and the frustration of playing telephone-tag. Of course he knows me already and I know him, and he sees me in the flesh at least once each year. Many pediatricians now have websites for their office practices and use them to distribute information to the parents of their patients as well as for e-mail.
Is there any way this kind of virtual medicine could work if there were no pre-existing relationship between doctor and patient? Could a doctor dispense useful advice without ever having seen the patient? The answer would depend upon the problem, of course — I would be leery of diagnosing and treating, say, pneumonia over the internet. But what about other things? Could an online exchange between a patient and a doctor be used to, for example, schedule an x-ray of a swollen, painful arm? The patient would still need to see the non-virtual doctor, but could this kind of practice save time and streamline the process? And what if the exchange was not by e-mail, but in real time?
A new company is trying to establish just such a system. Called American Well, it aims to offer not e-mail exchanges, but real-time conversations between patient and physician. I have no idea if this will work out, but I could see a system in which a pediatric practice with several pediatricians would assign one of them to spend chunks of time interacting with parents of children in their practice, using either instant messaging between doctor and patient or perhaps even a sort of internet chat room for general discussion with several patients. If this were linked to the scheduling system of the practice, tests could be arranged and follow-up appointments easily made. As a pediatric intensivist I can’t see my practice being changed by this brave new virtual medical world, at least for now. But who knows what’s coming.
Unfortunately my PICU colleagues and I sometimes care for children with gunshot wounds. It isn’t common, but it isn’t infrequent, either. In my experience, most of these are to the head, and most cause death or disability. Although gang-related violence occasionally affects adolescents, and thus our PICU practice, the majority of these wounds are accidental. The typical scenario is a child playing with a loaded gun, which then accidentally goes off. Less commonly, but still something I see, is a suicide attempt by a troubled adolescent, usually a boy.
There has been a great deal of research on the epidemiology of gunshot wounds, the best of which treats the problem as it would any other public health problem. You can read a good summary of that research here, although the article is by a person who favors some sort of gun control laws.
The root of the legislative debate about gun control concerns the meaning of the Second Amendment to the Constitution. Depending upon your politics, it either does or does not protect an individual citizen’s right to own guns for personal use. The best discussion of the legal ramifications I have seen is here, where a legal scholar examines both sides of the debate and concludes the arguments are nearly equally matched — both sides have valid positions. Thus, although partisans on both sides see their view as clearly correct, neither is.
For myself, although I grew up owning and using guns to hunt, I am convinced that a gun in the household makes it a more dangerous place for children, not a safer one.
If you look around a typical physician’s desk you will see pads of paper, pens, and various knick-knacks emblazoned with the brand-name of a particular drug. These are examples of the host of freebies doled out to physicians by drug companies, and anyone who has ever worked in a doctor’s office or clinic knows where these things come from — they come from drug reps, people who were called “detail men” in my father’s day, because all of them were men. They make the rounds with their bags of gifts and trinkets, hoping thereby to influence a doctor’s prescribing behavior. They often also bring treats and free lunches.
Is it reasonable to think a physician, an intelligent, highly-trained person, will actually make a decision about whether or not to prescribe a powerful medication based upon the fact there is a notepad on his desk with the drug name on it and he is writing the prescription with a free ballpoint pen? Actually, it happens. It’s been studied, in fact, and it shouldn’t surprise us that the drug companies are highly skilled at fine-tuning their individual pitches to doctors to make them more effective. What may seem like good-will gifts are simply investments from which they anticipate a return.
The pharmaceutical companies say these visits from Santa Claus serve an educational purpose, that the drug reps bring important information to busy physicians they would otherwise not have the time or inclination to discover on their own: in thirty years of practice I have never seen that to be true. You can read a fascinating description from a former drug rep about what his job really was, and what the companies thought they were buying with their baubles here. It found it to be quite an enlightening read, but it didn’t surprise me any.