An interesting recent editorial in the New England Journal of Medicine asks that doctors be explicit about what they will support and what they won’t. In particular, would we agree to pay cuts? The essay points out that, at least early in the process, drug companies, insurance companies, device manufacturers, and hospitals all agreed to some limitation on their income. (If they still would, of course, is another question.) But doctors have made no such pledge. In fact, as a group, we’ve demanded more of the healthcare pie. Is that fair?

I don’t think it is fair. To me, the biggest problem with physician salaries is that they are so spread out from lowest to highest in a manner that doesn’t really reflect training or expertise — the variance primarily reflects custom. My own family’s experience with medicine spans well over a century, with my grandfather graduating from medical school in 1903 and my father in 1944. Some doctors have always made more money than other doctors, either from being busier or from getting more training. Surgeons and other doctors who do procedures have always made more than those who don’t do these things, but the huge variance in physician salaries we have seen emerge in the past several decades is a new phenomenon. To me it parallels the huge (and recent) disparities we see between what a CEO gets paid and what an the average employee gets paid. Things have gotten out of balance.

If you want to learn more about how medical practice, including how it is paid for, emerged in the last century, there is no better book about it than The Social Transformation of American Medicine, by Paul Starr. The book won a Pulitzer Prize in 1984. And if you’re wondering: yes, I’d give up some salary to get healthcare reform, so long as everybody else would, too. It’s only fair.

That’s the title of an interesting editorial in a recent issue of the New England Journal of Medicine. It’s interesting because how people think about, and act towards, an epidemic is in many ways as important as the medical aspects of the disease. So the emotional epidemiology is important

The H1N1 vaccine became a controversial subject, although not among medical scientists. There were some glitches in the vaccine supply, but these are easily explained by the lack of lead-time in vaccine manufacture. Generally the manufacturers get about a year to produce the next year’s vaccine; in this instance they only got half that time. The interesting thing is that, by the time the vaccine became available in large quantities, the same people who were clamoring for it in mid-2009 (and upbraiding the system for not have it ready) were now suspicious of it, even afraid of it.

Why did this happen? One culprit, of course, is the voracious 24 hour news cycle that demands extreme stories. The “swine flu plague” played right into that. Another is that we physicians lack an appreciation for “emotional epidemiology,” causing a subsequent lack of vigor in addressing influential, but misleading articles, such as this one. (This article has been demolished in many places, such as here specifically and here, more generally.)

I’ve written before (here and here) about the reliable winter time arrival of RSV. This virus is the most common cause of pneumonia and bronchiolitis in children under six months of age. To scientists, RSV is a fascinating virus with several unique properties.

One of these is its behavior in the population. During its annual visitation, RSV is everywhere. Then it suddenly vanishes. There are exceptions to everything in medicine — I have seen sporadic cases during the off-months — but generally RSV arrives with a bang in mid-winter and then leaves suddenly in the spring. It is the only virus that consistently and reliably causes an epidemic every single year. Not even influenza does that. However, RSV epidemics may still have some regional variability. For example, often one city will have a much more severe epidemic than do others in other regions of the country.

Another aspect of RSV that interests medical scientists is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first year of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.

RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics.

RSV is generally not a serious illness, but for some children it can be life-threatening. These children are very small infants, especially those born prematurely, and those with underlying problems with their lungs or their hearts. For those infants we have a monthly shot that helps reduce the severity of RSV when they get it, and may even prevent a few cases, but this is not ideal.

Since RSV cannot be prevented, the best thing a parent can do is try to postpone it. That is, if you have a newborn infant in the height of RSV season, try to minimize exposure of your child to people with cold symptoms, especially toddlers. And for those who do handle your infant, have them wash their hands first.

By now everybody knows that the Senate passed a healthcare reform bill last week. The House passed such a bill last month. The bills differ in important respects, and of course it is still unclear if the two bills will be reconciled in conference committee to produce a bill that both houses will pass. If a final conference bill does pass, it will have ground-breaking effects on medical care. What might change in the PICU?

My first-blush answer is that it will have important effects for me, my colleagues, and our patients, but not so much as it might for other aspects of medical practice. Why do I say that? First, look at where our current healthcare dollars come from (source is here):

Private insurance: 35%
Medicare: 19%
Medicaid and SCHIP: 15%
Other public funds: 12%
Other private funds: 7%
Out-of-pocket: 12%

These figures are for the entire system. As I’ve written before, the PICU is different — very different. Around half of children in the PICU already are covered by Medicaid, the joint federal/state program for children of poor families. This startling statistic is a reflection of the fact that poor children are far more likely than are affluent children to end up in the PICU.

But even though half the children in America’s PICUs are on Medicaid, half are not, and the healthcare reform bill can have a major impact on them, especially those from families who are presently uninsured. A PICU bill can bankrupt those families. This bill will reduce the number of times that will happen, and I think that is a good thing.

The H1N1 strain of influenza — the “swine flu” — has gotten a lot of headlines this past year. You can find a summary of matters during the first half of 2009 here. That report studied 272 patients who were sick enough to be admitted to the hospital. Of these, 25% needed to be in the ICU. From my perspective, the interesting part was that nearly half were children; unlike usual influenza epidemics, only 5% were older than 65.

I didn’t see any severe cases of H1N1 until this past fall, but then I began to see quite a few of them. Of these, two were so severe that they required prolonged treatment with a mechanical ventilator, a breathing machine. Another child in our region was so severely ill that he required treatment with the most extreme kind of respiratory support, something called extracorporeal membrane oxygenation (ECMO). This machine bypasses the lungs entirely and uses a machine to get oxygen directly into the child’s bloodstream. Using ECMO is a complicated endeavor, one with high risks and high mortality. But sometimes it is all we have to offer.

My conclusion on the H1N1 flu is that it was every bit as severe as the experts predicted. Although the mortality was not anywhere near as bad as the great epidemic of 1918, we also have means of ICU support that physicians didn’t have back then. This year’s flu, like that of 1918, also seemed to affect the very young to a degree I haven’t seen before. To me, the massive campaign to vaccinate as many as possible was justified. Of course we don’t know if it helped reign in the epidemic thus far, but I think it probably has.

Since the beginning of the H1N1 (swine flu) influenza epidemic bottles of commercial hand sanitizer have been flying off the shelves. They’re everywhere in my son’s elementary school, for example, and I’ve seen them sitting on the counter and available for customer use in stores and banks. Is that gel worth it? Does simply washing your hands work just as well?

That question has been studied, quite directly, here. The investigators tested twenty volunteers who had been vaccinated against H1N1 influenza and who had had a blood test that documented that they were immune to the infection. So they couldn’t get sick from the virus. These volunteers then had live flu virus put all over their hands, after which they washed them either with soap and water or one of several hand sanitizers. The investigators then tried to recover live virus from the volunteers’ hands, and compared the results to how much virus they could obtain from the hands of volunteers who did not do anything except air-dry their hands.

The results showed that all methods dramatically decreased the amount of virus on the hands. Seventy percent of volunteers who did not wash with anything still had virus on their hands even an hour later. All of the hand cleaning techniques worked very well, but simple soap and water actually worked the best. So sanitizer is fine if you haven’t got a sink around, but wash your hands the old fashioned way if you do.

The issue of food allergies is a complex one, probably because the food we eat is complex stuff. Many parents observe that particular foods don’t agree with their child. Pain, bloating, and diarrhea are all symptoms that can be evidence of this. Often such parents will say that their child is “allergic” to a particular food that they see causing those sorts of symptoms.

A broader term for this is food intolerance, the observation that particular foods upset the child’s digestive system. There are many examples of this kind of thing. One of the most common is a deficiency along the intestinal wall lining of lactase, the enzyme that digests the sugar lactose. This is not an allergy — it means that the person is intolerant of lactose, the sugar in many milk products. This lactase deficiency may be inherited or acquired later. (You can read more about this problem here.)

To a physician, the word “allergy” has a very specific meaning: it means that parts of the child’s immune system are reacting to components of the food. A common offender is peanuts (about 1% of all children), but there are many others. The symptoms of these true allergies can be much more severe, and typically cause problems outside the digestive system. Hives and difficulty breathing, either from wheezing or from swelling in the throat, are not uncommon. We occasionally see children in the PICU who have these more severe reactions to food. Parents of such children often need to have an injectable medication, epinephrine, handy at all times if this happens.

How common are food allergies and intolerance? A recent study in the journal Pediatrics gives us some answers. The authors found that in 2007, 4% of children under 18 had some form of problem with food. This was an increase of 18% over the previous decade, although it was unclear if this was a real increase or simply reflected increased awareness among parents and physicians. This particular survey, although broad, did not distinguish between allergy and intolerance. However, the authors noted that it correlated with other, smaller studies in which true allergy was documented with specific tests. So it seems like a real phenomenon

Here is a recent article of mine published by Smartman Daily.

Most dads with a toddler have experienced the ear drum game. For the minority who haven’t, it goes something like this. Your child has a cold for a few days, but otherwise seems fine. Suddenly she spikes a high fever and clearly hurts somewhere. You take her to the doctor. He takes a very quick look–only seconds, it seems–at her ears and pronounces that she has an ear infection. By the age of three, eighty percent of all children will have had one, and half will have had more than one. Here are answers to six important questions about this common condition.

#1: How can a doctor be sure your child has one?
Here’s a trade secret–frequently we aren’t. If you ask five pediatricians to look in a child’s ear, you may well get five different opinions. This is why medical students call it the ear drum game–it seems whatever they say about a child’s ear, their instructor will say the opposite. Sometimes the diagnosis is obvious. The ear drum is inflamed and bulges outward from the pressure behind it. That pressure comes from infected fluid clogging up the normally air-filled middle ear cavity. Those are the easy ones. The tougher ones are ear drums that are somewhat red, a bit distorted in their shape, perhaps a little less mobile than usual. In those children doctors are often swayed by other things–fever, if the child seems to be pulling at her ears, if she has had past ear infections. These cases are judgment calls, but doctors often follow our old saying that “common things are common,” so we tend toward diagnosing ear infection if it is a borderline case.

#2: Where do ear infections come from?
The middle ear, the place where sound waves bouncing off the ear drum get passed along to the brain so a child can hear, is normally free of germs. There is a tube connecting the middle ear to the back of the nose, there to let air in and out. You can feel this happening when your ears pop going up and down in an airplane. The nose is normally thick with germs. The connecting tube has ways of keeping the germs out of the middle ear, but when those defenses break down the germs pounce on the opportunity, crawl up the tube, and cause an ear infection. The most common cause of tube malfunction is a viral respiratory infection, which is why an ear infection so frequently follows a cold. The tendency for the tube to malfunction also runs in families, which is why frequent ear infections do the same.

#3: Why do we treat ear infections with antibiotics?
An ear infection means germs in the middle ear, but often a child’s body can handle the germs without help. After all, children have been getting ear infections for eons and antibiotics have only been around for a half-century or so. Sometimes these germs aren’t even bacteria, so antibiotics would be of no use anyway. The practice among most American physicians over the past decades has been to treat all ear infections with antibiotics. The reason was to reduce the chances of a child getting one of the uncommon complications that can happen, and the number of these complications has dropped significantly in the antibiotic era.

#4: Okay, but do ear infections always need antibiotics?
For children over six months, the answer is no. The antibiotics-for-all approach has always been questioned by some doctors, especially for children older than two. These doctors reserve antibiotics for children whose symptoms last more than a day or so. This is a decision that should involve parents. Most want antibiotics, and there is nothing wrong with that–it is standard practice. But if you don’t want them, at least right away, another acceptable approach is to get a prescription for the antibiotic, but not fill it unless your child’s symptoms persist. More and more physicians and families are opting for this. Antibiotics are not risk-free. Either way, it’s a good idea to treat the ear pain and fever with medicines like ibuprofen (Motrin) or acetaminophen (Tylenol).

#5: What about prevention?
We know some things are associated with ear infections, and they share the property of contributing to malfunction of the tube between the middle ear and the nose. Exposure to tobacco smoke is one, because it irritates the lining of the nose. Another is putting a child to bed with a bottle, because every time a child swallows the tube opens wider. If the child is lying on her back, the nose bacteria have an easier time of reaching the middle ear.
Sometimes doctors prescribe a low dose of a daily antibiotic for a child who has had many infections. The more controversial kind of prevention is placing a plastic tube through the ear drum to connect the middle ear directly with the outside world. These so-called pressure equalization tubes work by helping keep the middle ear free of the fluid that gives bacteria a hospitable place to grow. If your child has a lot of ear infections, your doctor may recommend these. Besides talking to your doctor, you can learn more about the generally accepted reasons for placing tubes at several authoritative sites, such as here.

#6: Why do ear infections generally go away when a child gets older?
By the time a child gets to school-age, ear infections are uncommon. This is because, as the skull grows, the connecting tube gets longer and less straight, putting a useful mechanical obstacle in the way of germs trying to get up the tube to reach the ear. Additionally, older children get fewer colds than toddlers. So, if your child has a lot of ear troubles, take heart in the fact things will certainly get better over time.

Often children in the PICU need a mechanical ventilator — a breathing machine — so parents are confronted with this machine. When do we use them and how do they work?

There are three main reasons for using a ventilator: 1.) the child’s lungs are not working well, not getting needed oxygen into the body and carbon dioxide waste out (severe pneumonia is a good example); 2.) the child is not awake and aware enough to breathe and cough properly on his own (a head injury is an example); 3.) the child’s lungs and level of awareness are fine, but he is too weak to breath properly (various muscle problems are examples).

There are many different kinds of ventilators made by different companies, and superficially they may look very different from one another. They have an array of dials and flashing indicators on them, and most draw complicated graphs on a screen as the ventilator works. But in spite of this variability, at root all common ventilators are alike (there are exceptions — special machines we use in special situations). They give a child a breath of air down through a breathing tube, called an endotracheal tube, which we place through a child’s mouth or nose. That air nearly always has extra oxygen in it. We express this additional oxygen as a percent — ordinary room air is 21% oxygen (most of the rest is nitrogen) and pure oxygen is 100%.

We use all the knobs on the machine to set what kind of breaths we want — how big and how often. We also tell the machine what to do if the child takes a breath on her own, usually telling it to help the child in one of several ways with her spontaneous breathing attempts. Finally, we tell the machine what to do between breaths, typically to maintain some air pressure in the system (called PEEP, for positive end-expiratory pressure).

The whole point of using a ventilator is to take over the job of breathing from the child. The machine can do it all, or it can assist the child while she does some of the work. A mechanical ventilator is not an all or nothing device. After the child has healed and no longer needs the ventilator, we can progressively turn down the settings on the machine, in this way asking the child to take over her own breathing more and more. When she can do all the work herself, we pull out the breathing tube.

These principles are straightforward. But if your child, or one you know, needs a ventilator machine, you should know that managing a ventilator is a fine art — it can’t be done by cookbook. We have general guidelines we follow, but most pediatric intensivists have their own personal wrinkles in how they apply the guidelines, using what has worked for them over the years. Most importantly, each child is different and reacts to the ventilator differently, so its use needs to be tailored to each child.

Mechanical ventilators in the PICU are an excellent example of something that appears, on the surface, to be high-tech modern medicine in action. Using one successfully, though, takes some low-tech skills of the sort good physicians have used for generations.

The PICU is a very high-tech place — full of machinery that helps sick children breathe better, assists their hearts to beat better, and helps their kidneys do their job. The PICU room of a sick child can be stuffed with machines that flash, beep, and bing. We also have an array of monitoring devices that tell us how a child’s organs are doing. They alert us to when there are problems. They also give us evidence of when things are improving.

The interesting thing, though, is that often the first signs of improvement do not come from any of the machinery. Often an experienced eye — especially a parent’s eye — can sense that things are just better. The child simply looks better. There is no monitoring device that can replace that experienced eye.