I’ve worked in several PICUs over the years. Some were as large as 36 beds (which counts as pretty large in the PICU world), and some were as small as 4 beds. Inevitably, larger PICUs can offer services that smaller ones cannot. This is particularly the case with more specialized services, like some kinds of surgery and access to super-specialists. When I’ve been in a smaller unit, there have been times when I’ve needed to transfer children to a larger one so they could get these more esoteric services. When I’ve been in a larger unit, I’ve received transfers of kids like that. Would these children who needed transfer have been better off going to the larger PICU in the first place?
The dilemma for smaller PICUs is that they can never become as experienced in caring for children with rare conditions, and it is hard for someone working in one of the smaller units to keep their skill levels up. Research has shown, not surprisingly, that physicians who do the same thing a lot are better at doing it than physicians who don’t do it so often. On the other hand, transferring a child from a local, smaller PICU to a bigger one is often hard on families, since often the larger unit is in another city — sometimes in another state. And many PICU problems can be handled just fine in a smaller place, nearer to home.
The process of transferring a critically ill child — by ambulance, helicopter, or airplane — carries risks, too. These risks are not just those inherent in traffic or flight. I can tell you from personal experience that no matter how much supplies and equipment you bring on the transport, you still can’t recreate a PICU. And the simple working environment of a transport vehicle, especially a helicopter, is cramped and noisy — far from optimal. So sometimes a critically ill child is safer staying where they are, at least until they can be made more stable.
What to do? As pediatric intensivists, we are sort of feeling our way as we figure this out. Most smaller PICUs have formal or informal relationships with larger units to which they can send children they cannot handle. But these relationships are a patchwork across the nation — we simply don’t know the ideal size for a PICU. When PICUs began several decades ago they were rare, found only in large children’s hospitals. In those days people’s expectations were different about what smaller community hospitals needed to provide. In today’s world, we believe all children should have access to the same life-saving PICU care. So smaller hospitals began to open PICUs to provide that care as best they could. Someday PICU care may be truly regionalized, with formal relationships between big and small units in the region, complete with standardized criteria for appropriate care at one unit or the other. We don’t have anything like that yet.
What parents should realize is that there are differences between what a smaller and a larger PICU can do. If your child has a particularly unusual or difficult problem, it is never inappropriate to ask your child’s doctor if transfer to a larger unit makes sense.
I recently ran across this incredible image, a painting by Edvard Munch. He called it “the sick child.” The artist painted from memory his younger sister, ill with tuberculosis.
It has taken only a couple of generations for Americans to forget one of the great killers of history — tuberculosis. Sixty years ago Rene and Jean Dubois wrote a historical study of TB that still stands as a landmark study. It’s a fascinating book, written in 1952, just about the time we at last had effective antibiotic treatment for TB.
Tuberculosis was the most common cause of death during the nineteenth century, responsible for around a third of deaths. Think about that for a minute — a third of all deaths. Many, many of those dying were children. Adolescents and young adults were also common victims. I find Munch’s image of his sister, with her pallid eyes and hollow cheeks, to be much more haunting than the artist’s more famous images, such as the series collectively called “The Scream“. This one is the face of innocent suffering. TB killed her, as it did millions of other children.
Because of antibiotics tuberculosis no longer kills children in America. But the bacterium is a crafty one, devising ways to resist antibiotic action. We are really only one jump ahead of this ancient scourge.
You can find more specific information about TB here, and about its history here.
I wrote about this some months back, but recent conversations with parents have reminded me once again that medicine is an odd mixture of science, near science, intuition, guesswork, and blind luck. A particularly knotty problem is how to know if what we’re doing does any good. Consider it this way:
Medicine is particularly prone to be trapped by the well-known fallacy with the fancy Latin label of post hoc, ergo propter hoc – or, after this, therefore because of this. This is because, when a patient comes to us with a particular problem, physicians generally do things, like prescribing medicines and do procedures. We intend for what we do to help the situation, but often there is no way to tell if it has. The patient may improve; or the patient may not. What follows may be related to our treatment, or it may not be.
Even if there is good scientific evidence that a treatment works, that evidence generally relates to populations of people, not an individual. And individuals are, well, individual. A person is not a statistic. So if a treatment is a really, really good one, for example one that helps 90% of the time, 10% of the time it won’t help. It might even make the condition worse for some individuals.
Anyone who has watched late-night cable television has seen countless examples of this logical trap, in the form of personal testimonials from people who had this or that problem, took the pill or bought the product, and the problem went away. The fallacy, of course, is that the two events may be entirely unrelated, just as the fact I may drink coffee every morning before the sun comes up does not cause the heavens to move in that way. I’ve written about this in a little more detail here.
This uncertainty can drive a precise mind a little crazy. But for me it’s one of the things that makes practicing medicine fascinating.
Courtesy of one of my favorite sites, xkcd, here is an example of how medical research gets reported by those with an axe to grind:
Another version: if you already think you know the answer, and therefore will not be swayed by the data, don’t do the research.
I wrote about this a while back, but it’s worth revisiting because parents should be cautious about overreacting to medical research news. I see this all the time. Anyway, Liz Szabo wrote an interesting news report in USA Today concerning an article in Pediatrics, the official journal of the American Academy of Pediatrics. The article described an apparent association the authors found between early feeding of solid food (age younger than 4 months) and obesity at age 3 years. The association was only present in children who were formula-fed and not breast-fed. To restate: the authors found that, in formula-fed babies, early introduction of solid food was associated with being overweight at age 3. Early introduction of solid food in breast-fed babies had no effect.
What I found most interesting about Ms. Szabo’s article, although it was quite good, was the comment trail; it showed how most folks really don’t understand how to interpret medical studies. Some of the commentators denied the possibility of such an association because of their own experience with their children. Other commentators immediately leaped to the conclusion that the study authors were claiming feeding solids before the age of 4 months to your formula-fed infant would make them all fat. Still other commentators decried the “breast-feeding Nazis” who insist mothers who choose not to breast feed are negligent and try to make them feel guilty. If any of the commentators took the time to read the full study (it’s available free online here), they would have found that the authors make no such sweeping claims.
First of all, the study is observational. That means that the authors merely collected information about mothers and babies. There was no intervention, such as convincing mothers who chose not to breast-feed to nurse their babies, or vice-versa; the mothers chose, and the investigators merely watched what happened over the next 3 years. This approach leaves any study like this wide open to selection bias — the possibility that the 2 groups of mothers differed in some other way than feeding choice, possibly in a way that would influence that choice and future obesity in the children. The authors did examine a few possible confounders like this, education and family income, but there are many other possible ones.
What did the authors find, really? Well, they studied a total of 847 infants — 568 breast-fed, 279 formula-fed. Within those groups, 43 of the breast-fed babies started on some solids before 4 months (7.5%). In contrast, 91 of the formula-fed infants had started solids before 4 months (33%). So clearly mothers of formula-fed babies were more likely to start solids sooner, for whatever reason. That might matter for the ultimate results or it might not — there’s no way to tell.
At 3 years of age, 3 of the 43 breast-fed babies who had early solids were obese — 7%. In contrast, 23 of the 91 formula-fed babies were obese — 25%. To a statistician, that’s a significant number. It means there’s an association between 2 things. But it does not prove causation of anything. And note that 75% of the formula-fed babies were not obese at age 3, so personal anecdotes from commentators don’t mean much.
The bottom line to me is that this is an intriguing study, but it is far from the last word on it. And most of the irate commentators to the USA Today article complained about things that the authors of the article didn’t claim. So, whenever possible, it is good to read the original study before you decide anything — or get upset about it.
If you’ve ever been inside a PICU, or any ICU for that matter, I’m sure you were surrounded by fancy-looking equipment. There are monitors coming off the wall that measure a large assortment of patient variables. These can include include heart rate, breathing rate, blood pressure, amount of oxygen in the blood, amount of carbon dioxide in the patient’s breath. If the patient has various invasive monitoring devices in place in the bloodstream, or even in the brain, the monitors measure pressures inside the blood vessels and brain. Most of these monitors also display a waveform of these things moving across a screen in multiple colors. It’s very impressive-looking. If the patient is on a mechanical ventilator, a breathing machine, it has monitors built into it, too. This child has a bunch of those, including the brain one.
We use these monitors to measure important things, and they all have alarm settings that go bing or bong, often quite loudly, if the thing the monitor is measuring drifts outside whatever parameters are set for the monitor. That’s for safety. But many of those monitors are so sensitive that one or another of them is always making noise. Nurses are frequently resetting one or another of the alarm buttons. Virtually all the time it’s a false alarm in that the particularly bing or bong is not significant for the patient. Often it means there’s something amiss with the monitor.
I think you can see where this is going — alarm fatigue sets in. With so much alarm noise, most of it like the proverbial boy calling wolf, it can be a problem when to know when there’s a real wolf in the room. The FDA has recognized the problem, which I can tell you from practical experience is a real one, by scrutinizing new medical equipment for a balance between alarm sensitivity and usefulness. You can read more about that here.
The best advice for doctors and nurses in dealing with this issue is what the good ones always do: when some alarm goes off indicating a problem, look at the patient more than the monitor.
One of the four key principles of standard medical ethics is the principle of autonomy, which I’ve written about here. Autonomy means that patients are in control of their own bodies and make the key decisions about what sort of medical care they will (or will not) receive. For children, this principle means that the child’s parents make these decisions.
There are exceptions, as with all things in medicine. For example, if a child’s physicians believe that the parent’s choice will harm the child, the physician can ask a court to intervene. This is a very rare occurrence, but it happens sometimes. I have been involved in a few of those cases. But that’s not what I’m writing about now — I’m writing about nearly-adults, those children who are almost independent, but not quite.
The law generally defines the age of majority, the point at which a child is no longer a child and may decide these things for herself, at age eighteen, although there are variations between states. (The age is younger for so-called emancipated minors – those children who are entirely self-supporting or who are married.) What should we do when such a near-adult and her parents disagree about the treatment the child should get? There have been several recent examples of the variety of things that can happen then.
One case is that of Dennis Lindberg, a fourteen-year-old boy who died from leukemia in 2007. Dennis was a Jehovah’s Witness and, like others in his faith, rejected blood transfusions, even in life-saving situations. It is common for the courts to mandate transfusions in very small children over the objections of Jehovah’s Witness parents. The rationale for this is that a small child is too young to decide himself if he agrees with his parents. Dennis’s doctors went to court to get such an order.
But this case was different — Dennis was not a toddler or small child. He was an aware, articulate, young man who understood the meaning of both his illness and the consequences of not getting the transfusion. The court ruled that Dennis had the right to make his own choice, which he did.
His case dramatized a very grey area in medical ethics — when ought a young person be able to make these decisions on his own? In my own career I have had several occasions when an adolescent disagreed with the doctors, his parents, or both about what to do. In all those situations everyone eventually came to an understanding. That’s the best outcome, of course, but these will always be ambiguous situations because children mature at differing rates. Some thirteen-year-olds are wiser than seventeen-year-olds. For that matter, some young adolescents are wiser than others who have already attained the magic age beyond which we give them the right to make all these decisions.
If you are interested in these kinds of ethical questions as they relate to children, here is another example of a teen (with the support of his parents) going to court to assert his right to refuse standard therapy for cancer.
I’ve written before about how the current standard of care is to provide some sort of sedation drugs — by mouth or by injection — to relieve pain and anxiety when we have to do things to children that make them uncomfortable, such as sewing up lacerations or doing x-ray studies that require them to lay still for a prolonged period. Pediatric intensivists in particular have become very involved in providing this service for children. There’s even a new professional organization, the Society for Pediatric Sedation, that gathers together doctors and nurses involved in this practice. (I’m a member.)
We have a menu of medications to choose from, but finding the perfect sedative for children is sometimes difficult. All of them have potential issues, although we are used to dealing with these things. Recently there’s been a new agent on the pediatric sedation scene, although it’s been around for many years for other uses — nitrous oxide, aka “laughing gas.” It’s been used in the operating room for many decades as a supplement to more potent anesthetics, and outside the operating room in dental offices for well over a century. It has an outstanding safety profile. One of the pioneers in using nitrous oxide for sedating children for medical procedures is Dr. Judy Zier, of Minneapolis Children’s Hospital. For the past year we’ve been using nitrous oxide at my hospital, and for many children it is very helpful. It seems to be most helpful for children between about two years of age and ten or so. We now typically use it for many things we just used to do without any sedation at all — placing intravenous (IV) lines, urinary catheters, and nasogastric tubes. I think it represents a real advance in what we can offer children. Being in the hospital is frightening enough for a child.
Like many of my colleagues, I teach and supervise students, residents, nurses, and respiratory therapists. I’m also the medical director of a PICU. Overall, I’ve been teaching and doing administration for over 30 years. And, like most of my colleagues, I never received any formal instruction at all in how to do these things. To some extent I got help from my own mentors, primarily by watching what they did, but basically I learned on the job. I hope I am reasonably good at it, but really, I have little way of knowing if I am. So I’ve always had an interest in whatever tidbits I could pick up in teaching theory that might be useful. One particular topic that’s always interested me is the opposing pros and cons of reward versus punishment. I use those tools to train my horse – rebuking bad and praising good behavior. What do we know about applying them to people?
The practical problem, one faced by most teachers, is what to do when a student does a poor job. The tradition in medical teaching, certainly when I was in training, was to lean heavily on the rebuking, punishing side of the equation. Public ridicule was common, and there was more than a little yelling involved. Did fear of that help me avoid doing the wrong thing next time?
A while ago I was reading one of my favorite group blogs, Crooked Timber. Most of the contributors are professors of one sort or another, and the topic of effective teaching comes up now and then. This whole reward/punishment tension was the topic of a post there. The situation it describes involves military flight instructors, who universally believed that yelling at fledgling pilots when they made mistakes was much more likely to make their next attempt better than was praising a good action. Here’s what one instructor had to say about it:
“On many occasions I have praised flight cadets for clean execution of some aerobatic maneuver, and in general when they try it again they do worse. On the other hand, I have often screamed at cadets for bad execution, and in general they do better. So please don’t tell us that reinforcement works and punishment does not, because the opposite is the case.”
It’s a military example, but training doctors has traditionally been done using that sort of get tough model. I was aware of a statistical principle called the regression to the mean, but this example applies it to teaching in a way I hadn’t thought about. The argument goes like this.
If a given student does a bad job at something, that is more likely to be a low point for them, below their average. Statistically speaking, they are more likely to do better on the next attempt no matter what the teacher does. So the teacher is likely to think whatever he or she did – screaming, for example – as causing the improvement. On the other hand, if a student does an exceptionally good job, the same regression to the mean makes it likely the next attempt won’t be as good, so whatever the teacher does – in this case praising – tends to cast doubt on the usefulness of praise.
For myself, I think praising, in the long run, works much better. I’d be interested in what any professional teachers think about this.
In the comment trail to the article, the classic The Art of Raising a Puppy was cited as a useful source. I found that very interesting. After all, to those of us with more than three decades in medicine, medical students are a little like puppies. We want to give them a sound foundation and train them without hurting them.
No pediatrician I know has ever liked any of the many over-the-counter cough and cold remedies very much, especially for very young children. There never has been any evidence that they help cold symptoms, and what’s in them (typically a decongestant and an antihistamine) can cause actual harm to children. Risking harm for dubious benefit is never a good trade-off in medical practice. I’ve seen more than a few kids over the years need to be admitted to the PICU because they have overdosed on these medications, either because they got into the meds and took them themselves or because their parents miscalculated the dose and gave too much.
Recognizing the problem, the makers of these products agreed voluntarily several years ago to take the ones intended for children less than two years of age off the market. These were usually various kinds of drops. Did this new policy have any effect? A recent study in the journal Pediatrics, the official journal of the American Academy of Pediatrics, suggests that it did.
The authors looked at emergency room visits before and after the product withdrawal went into effect. They sampled sixty-three representative pediatric emergency rooms across the country. What they found is that the number of trips to the ER for untoward effects from these medications — overdoses or just funny reactions — dropped by half. Such ER visits for children older than two did not change. Of course, as we say, correlation doesn’t prove causation, so it may have been a coincidence. But I don’t think so — I think the new policy helped.
It’s good that ER visits from the ill effects of over-the-counter cold remedies dropped for young children, but there still were too many of them — 1,248 in the sample hospitals. That’s a lot of risk for no benefit at all. For children over two years of age, there were nearly ten thousand ER visits for this problem. That concerns me just as much. Roughly two-thirds of the cases were ones in which unsupervised children took the medicine themselves, but fully a third of them were because parents gave the children the medication. My advice — don’t use these agents unless your doctor suggests them (and fewer and fewer do), and never in children less than four.
Every parent should know where to find the number of their local poison control center — it’s generally in the front pages of the telephone book. Call them if you have any questions about drug effects — they are always very helpful and you might save yourself and your child a trip to the emergency department.
